Exhibits
The nurse comes into the room to replace the IV bag and notices the client's extremities are jerking violently. The client is not arousable and the oxygen saturation is 59% on the monitor.
Complete the following sentence by choosing from the lists of options.
Based on the information collected, the client is likely experiencing
related toThe Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
Based on the information collected, the client is likely experiencing Hypoxia related to Tonic clonic seizure
Rationale
The severe drop in oxygen saturation and the observation of violent jerking movements are consistent with a tonic-clonic seizure, which can be precipitated or exacerbated by significant hypoxia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["31"]
Explanation
Total volume in mL x Drop factor) / Total time in minutes.
For the vancomycin infusion, the total volume is 250 mL, the drop factor is 15 gtt/mL, and the total time is 120 minutes (2 hours).
The calculation is as follows: (250 mL x 15 gtt/mL) / 120 minutes = 31.25 gtt/min.
After rounding to the nearest whole number, the nurse should regulate the infusion to 31 gtt/min.
Correct Answer is C
Explanation
A. This would indicate fluid volume deficit, not improvement. Increasing IV fluids should lead to a decrease in hematocrit, not an increase.
B. This is not a desired outcome for a patient with pancreatitis, as hyperglycemia is a common complication. The focus should be on maintaining stable blood glucose levels.
C. BUN is a marker of kidney function and hydration status. A decrease in BUN indicates improved renal perfusion, which is a therapeutic outcome of increasing IV fluids.
D. While a decrease in amylase is generally a good sign for pancreatitis, it is not a direct result of increasing IV fluids. Amylase levels decrease as the pancreatitis improves.
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