Exhibits here

The nurse is implementing solutions to provide care.

Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided.

The nurse determines that the client's is still having an adverse reaction resulting in symptoms of
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Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D","dropdown-group-3":"F"}

A. being cold: Being cold is not directly related to the symptoms described in the scenario.

The client's symptoms include dizziness, headache, burning feeling on extremities, and redness on face and extremities, but there is no mention of feeling cold.
B.   dyspnea: Dyspnea, or difficulty breathing, may occur as a result of an adverse reaction such as anaphylaxis or severe cardiovascular compromise. It is a concerning symptom that warrants immediate attention and intervention.

C.   shaking: Shaking is not mentioned in the client's symptoms in the scenario. While it can be a sign of distress or discomfort, it is not directly related to the symptoms of dyspnea, nausea, and headache described.
D.   nausea: Nausea is a common symptom associated with adverse reactions to medications, including allergic reactions or cardiovascular events. It can contribute to the client's overall discomfort and may indicate ongoing or worsening adverse effects.
E.   blood pressure 116/68 mm Hg: The client's blood pressure of 116/68 mm Hg is not

indicative of ongoing adverse reactions. While the initial blood pressure reading was low (108/46 mm Hg), it is not included as part of the ongoing symptoms described.
F. headache: Headache can be a manifestation of various adverse reactions, including allergic reactions or changes in blood pressure. It is a symptom that should be monitored closely as it can indicate ongoing or worsening complications.

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Correct Answer is C

Explanation

A. Clamp the chest tube immediately with a plastic clamp. Clamping the chest tube can lead to tension pneumothorax, which is a life-threatening complication. It should never be done unless specifically instructed by a healthcare provider.
B. Apply an occlusive dressing over the chest tube site. This action is not indicated in this situation and could interfere with drainage.
C. Ensure the chest tubing is not kinked or hanging low. This is the correct intervention as a kinked or dependent chest tube can impede drainage, leading to respiratory distress.
D. Reinforce the chest tube connection to the container with tape. While ensuring the chest tube connection is secure is important, it is not the priority in this situation where the client is experiencing sudden shortness of breath.

A. Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed. B. Advise the UAP to document the last blood pressure obtained on the client's graphic sheet. C. Estimate the blood pressure by assessing the pulse volume of the client's radial pulses. D. Document why the blood pressure cannot be accurately measured at the present time.

Correct Answer is C

Explanation

A. Demonstrating how to palpate the popliteal pulse is not a suitable alternative for measuring blood pressure when the client cannot be measured in the arms or legs. Palpating peripheral pulses does not provide accurate blood pressure measurements.

B. Advising the UAP to document the last blood pressure obtained is insufficient because it does not address the need for current blood pressure monitoring. Documentation of past
measurements does not provide real-time information about the client's hemodynamic status.

C. Estimating the blood pressure by assessing the pulse volume of the client's radial pulses is a reasonable alternative when traditional blood pressure measurement sites are inaccessible. Although not as accurate as traditional methods, assessing the strength of peripheral pulses can provide valuable information about perfusion and blood pressure status.

D. Documenting why the blood pressure cannot be accurately measured is important for record- keeping but does not address the need for ongoing blood pressure monitoring or provide an alternative method for assessment.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured in the arms because the client has casts on both arms and is unable to be measured in the legs because the client is in the supine position. Which action should the nurse implement?

Correct Answer is C

Explanation

Oxygen at 5 L/minute per nasal cannula is being administered to a 10-year-old child with pneumonia. When planning care for this child, which principle of oxygen administration should the nurse consider?

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