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 A
Explanation
A banana allergy is often connected to a latex allergy.
This is because some of the proteins in the rubber trees that produce latex are known to cause allergies, and they are similar to the proteins found in some nuts and fruits, including bananas.
This syndrome is known as latex-food syndrome or latex-fruit allergy.
Choice B is not the answer because there is no known cross-reactivity between bananas and anesthetics.
Choice C is not the answer because there is no known cross-reactivity between bananas and povidone-iodine.
Choice D is not the answer because there is no known cross-reactivity between bananas and adhesive tape.
Correct Answer is A
Explanation
Administering IV fluids can help maintain blood flow to the kidneys and prevent acute kidney failure.
Choice B is incorrect because inserting a urinary catheter does not prevent acute kidney failure.
Choice C is incorrect because an intravenous pyelogram is a diagnostic test and does not prevent acute kidney failure.
Choice D is incorrect because beta-blocker therapy is not used to prevent acute kidney failure.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today