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Exhibits

Highlight the 3 orders that should be completed first.

Orders

Administer oxygen 5 L/minute via simple face mask

Vital signs ever 1 hour

X-ray of the right arm and cervical spin

Place 2 large bore peripheral IV's

Computed tomography scan of the brain

Give 1 Liter bolus of 0.9% sodium chloride solution IV once

Bacitracin applied topically to lacerations every 12 hours

Administer oxygen 5 L/minute via simple face mask

Bacitracin applied topically to lacerations every 12 hours

Place 2 large bore peripheral IV's

X-ray of the right arm and cervical spin

Computed tomography scan of the brain

Vital signs ever 1 hour

Give 1 Liter bolus of 0.9% sodium chloride solution IV once

Answer and Explanation

The Correct Answer is ["A","C","G"]

A. Administer oxygen 5 L/minute via simple face mask: Oxygen administration is a priority intervention to improve oxygenation and address the client's low oxygen saturation of 82%.
Hypoxemia can lead to tissue hypoxia and further compromise the client's condition. Therefore, administering oxygen should be the first action taken to ensure an adequate oxygen supply to vital organs.
B. Bacitracin applied topically to lacerations every 12 hours: While wound care is important, administering oxygen and establishing IV access take precedence over topical
treatment. Oxygenation and fluid resuscitation are critical in the immediate management of a trauma patient to ensure adequate tissue perfusion and oxygen delivery.

C. Place 2 large bore peripheral IV's: Establishing IV access is essential for administering medications and fluids rapidly. This is particularly important in this scenario where the client may require immediate fluid resuscitation due to hypotension (blood pressure of 83/41 mm Hg).
Large bore IV access allows for rapid infusion of fluids and medications to stabilize the client's hemodynamic status.

D. X-ray of the right arm and cervical spine: While diagnostic imaging is important for assessing injuries, it is not as urgent as administering oxygen and establishing IV access. Oxygenation and fluid resuscitation are higher priorities to stabilize the client's condition before proceeding with diagnostic tests.

E. Computed tomography scan of the brain: While a CT scan of the brain is essential for assessing potential head injuries, the immediate focus should be on stabilizing the client's oxygenation and hemodynamic status. Administering oxygen and fluids take precedence over diagnostic imaging to address the client's hypoxemia and hypotension.

F. Vital signs every 1 hour: Monitoring vital signs is important for ongoing assessment, but it is not as urgent as administering oxygen and fluids. Vital signs should be monitored closely, but immediate interventions to address hypoxemia and hypovolemia are critical to stabilize the client's condition.

G. Give 1 Liter bolus of 0.9% sodium chloride solution IV once: The client's hypotension (blood pressure of 83/41 mm Hg) indicates hypovolemia and the need for fluid resuscitation. Administering a bolus of intravenous fluids (1 Liter bolus of 0.9% sodium chloride solution) is essential to address hypovolemia and improve perfusion to vital organs. This intervention helps stabilize the client's blood pressure and prevent further deterioration of her condition.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Keep diabetic medication on schedule as prescribed.

This is the correct answer because maintaining a regular schedule for diabetic medication is crucial for managing blood glucose levels and preventing complications.

B. Limit maximum daily fat intake to 15% of total calories.

While reducing fat intake can be beneficial for overall health, it is not directly related to managing acute blood glucose levels or preventing immediate complications of diabetes.

C. Check blood sugar levels every four to six hours every day.

Frequent monitoring of blood sugar levels is important, but checking every four to six hours may not be necessary for all clients, especially if they are not on insulin or if their diabetes is well-controlled. It depends on individual needs and physician recommendations.

D. Restrict alcoholic beverages to no more than 1-2 per week.

Limiting alcohol intake is good advice for overall health and diabetes management, but it is not the most critical action compared to keeping medications on schedule to prevent complications.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"B"}

Explanation

A. anaphylaxis

The correct answer is A. Anaphylaxis is a severe, life-threatening allergic reaction that can occur in response to medication administration. The client's symptoms of dizziness, headache, burning feeling on extremities, and redness on face and extremities, along with the sudden onset of symptoms after starting vancomycin infusion, are indicative of a possible anaphylactic reaction.

B. arrhythmias

The correct answer is B. Arrhythmias refer to abnormal heart rhythms, which can be

triggered by various factors including medication reactions. Given the client's history of symptomatic bradycardia and the sudden onset of symptoms after starting vancomycin infusion, arrhythmias such as bradycardia or other rhythm disturbances are a concern.

C. Cardiac arrest

The correct answer is C. Cardiac arrest is the cessation of normal heart function, which can be precipitated by severe arrhythmias or anaphylaxis. The client's symptoms, along with the drop in blood pressure, indicate a potential risk of progressing to cardiac arrest if not promptly treated.

D. Necrosis

Necrosis, or tissue death, is not typically associated with the symptoms described in the scenario. While vancomycin infusion can potentially cause tissue irritation or damage at the
injection site, the symptoms described suggest a systemic reaction rather than localized tissue necrosis.

E. Renal failure

Renal failure is not directly indicated by the symptoms described in the scenario. While vancomycin can be nephrotoxic in some cases, the symptoms of dizziness, headache, and redness are more suggestive of an allergic or cardiovascular reaction.

F. Peripheral edema

Peripheral edema, or swelling in the extremities, is not indicated by the symptoms described in the scenario. The client's symptoms, such as dizziness, headache, and redness, are more
indicative of a systemic reaction rather than localized swelling.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing teaching to a client admitted with a blood glucose level of 580 mg/dL about preventing complications related to diabetes mellitus. Which information reported by the client indicates understanding?

Correct Answer is A

Explanation

Exhibits The nurse would determine what actions to implement in an emergent situation. Drag from Word Choices to complete the sentence. The client is at immediate risk for developing dropdown-1,dropdown-2 and dropdown-3

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"B"}

Explanation

A client with a right hemopneumothorax has a chest tube connected to suction. While turning to the left side, the client becomes suddenly short of breath and anxious. Which intervention should the nurse implement?

A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take?

The nurse is providing discharge instructions to a client with gout in the left great toe who received a prescription for prednisone 30 mg by mouth to be administered each day. Which symptom should the nurse explain is most important for the client to report to the healthcare provider?

The nurse is providing postoperative care for an adolescent who had an amputation of the left leg for osteosarcoma. The adolescent describes experiencing phantom limb pain. Which non pharmacological intervention should the nurse provide?

The client is a 26-year-old female who fell from an apartment balcony. She was transported to the hospital via ambulance. The client enters the emergency room on a stretcher and is met in the trauma bay by the nurse. For the primary survey, what 2 things should the nurse do first?

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When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which action should the nurse implement?