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.

Answer and Explanation

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.

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Correct Answer is ["B","D"]

Explanation

Apricots and nuts are low-purine foods that can be included in a low-purine diet.

Sardines are high in purine and should be limited or avoided.

Scallops are high in purine and should be limited or avoided.

Liver is high in purine and should be limited or avoided.

A. Glasgow Coma Scale score changes from 14 to 9. B. WBC count changes from 9,000 to 16,000/mm. C. Pulse pressure changes from 30 to 20 mm Hg. D. Bilateral pupil diameter changes from 4 to 2 mm.

Correct Answer is A

Explanation

A decrease in the Glasgow Coma Scale (GCS) score indicates a decline in the client’s level of consciousness and neurological function.
This can be a sign of increased intracranial pressure or other complications related to the skull fracture.
Choice B is incorrect because an increase in WBC count may indicate an infection, but it is not as concerning as a decrease in GCS score.
Choice C is incorrect because a change in pulse pressure may indicate changes in cardiovascular function, but it is not as concerning as a decrease in GCS score.
Choice D is incorrect because a change in pupil diameter may indicate changes in neurological function, but it is not as concerning as a decrease in GCS score.

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Naxlex Comprehensive Predictor Exams

A nurse is planning to teach a client whose provider has prescribed a low-purine diet. The nurse should plan to instruct the client that he can include which of the following foods in his diet? (Select all that apply.).

Correct Answer is ["B","D"]

Explanation

A nurse is caring for a client admitted with a skull fracture. Which of the following assessment findings should be of greatest concern to the nurse?

Correct Answer is A

Explanation

A nurse is preparing to administer piperacillin 3.375 g by intermittent IV bolus every 6 hr. Available in piperacillin 3.375 g in dextrose 5% in water (DsW) 100 mL to infuse over 30 min. The nurse should set the IV pump to deliver how many mL/hr?

A nurse is caring for a client who has advanced liver disease. Which of the following laboratory results should the nurse monitor when assessing this client?

A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report?

A nurse is caring for a client who is 6 hours postoperative following the application of an external fixator for a tibial fracture. Which of the following actions should the nurse take?

A nurse is assessing a client who has a new diagnosis of diverticulitis and reports that he uses multiple complementary and alternative healing therapies. Which of the following complementary therapies should the nurse identify as contraindicated for the client?

A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching?

A nurse in the PACU is caring for a client. Which of the following assessments is the nurse's priority?

A nurse is caring for a client in the emergency department who experienced a full-thickness burn injury to the lower torso 1 hr ago. Which of the following findings should the nurse expect?