Exhibit 1 Exhibit 2 Graphic Record Blood pressure 176/122 mm Hg Heart rate 136/min Respiratory rate 32/min Exhibit 3 O2 saturation 88%.
A nurse in the emergency department is caring for a client who was involved in an explosion.
Which of the following actions should the nurse plan to take first? (Click on the "Exhibit" button for additional information about the client.
Obtain an ECG.
Calculate the extent of burns using the rule of nines.
Notify the Rapid Response Team.
Initiate peripheral IV access.
The Correct Answer is C
The nurse should plan to notify the Rapid Response Team first.
The client’s blood pressure is elevated, heart rate is high, respiratory rate is high, and oxygen saturation is low.
These are all signs of potential instability and the Rapid Response Team should be notified immediately.
Choice A is incorrect because while obtaining an ECG may be important, it is not the nurse’s first priority in this situation.
Choice B is incorrect because while calculating the extent of burns using the rule of nines may be important, it is not the nurse’s first priority in this situation.
Choice D is incorrect because while initiating peripheral IV access may be important, it is not the nurse’s first priority in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
“I should expect less than 25 mL of secretions per day in the drainage devices.” After a mastectomy with breast reconstruction using a tissue expander, you may go home with drains in your chest to remove extra fluid.
Choice A is wrong because performing strength-building arm exercises using a 15-pound weight is not recommended.
Choice B is wrong because waiting 2 months before additional saline can be added to the breast expander is not accurate.
Choice C is wrong because keeping the left arm flexed at the elbow as much as possible is not recommended.
Correct Answer is D
Explanation
Lithium. Lithium is a medication that has been associated with an increased risk of developing diabetes insipidus. This is because lithium can interfere with the function of the kidneys and their ability to respond to antidiuretic hormone (ADH), which regulates the balance of fluids in the body.
Atorvastatin (choice B) is a medication used to lower cholesterol levels and has not been associated with an increased risk of diabetes insipidus.
Propranolol (choice A) is a beta-blocker used to treat high blood pressure and heart conditions and has not been associated with an increased risk of diabetes insipidus.
Ranitidine (choice C) is a medication used to reduce stomach acid production and has not been associated with an increased risk of diabetes insipidus.
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