Exhibits

The nurse reviews the prescriptions and plans initial steps for caring for the client. Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

Palpate and compare radial pulses.

Administer ondansetron 4 mg IV.

Perform range of motion.

Check capillary refill on bilateral upper extremities.

Inspect the bandage for drainage.

Provide morphine 2 mg IV push (IVP).

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Rationale:

Palpate and compare radial pulses: It is important to check radial pulses to assess circulation to the injured limb. Decreased pulse strength, especially in the left arm, could indicate vascular injury, which requires immediate attention.
Administer ondansetron 4 mg IV: The client is feeling nauseated and worries about vomiting, likely due to postoperative effects, pain medication, or anesthesia. Ondansetron is an antiemetic, which is appropriate to administer to manage nausea and prevent vomiting.
Check capillary refill on bilateral upper extremities: Checking capillary refill is essential to assess perfusion to both arms. The client’s left arm is experiencing coolness, and diminished pulses were noted earlier, so this is necessary to monitor blood flow and prevent complications like compartment syndrome.
Inspect the bandage for drainage: After surgery, it is important to inspect the surgical site for any drainage, bleeding, or signs of infection. This helps ensure that there are no complications or issues with wound healing.

Perform range of motion: Performing range of motion exercises is contraindicated immediately after trauma, especially with a fracture or suspected injury to the shoulder. The shoulder should be immobilized to prevent further damage and to facilitate proper healing. Early movement may worsen the injury or cause additional pain.
Provide morphine 2 mg IV push (IVP): While he had a nerve block, its effectiveness will wane, and he will likely experience significant pain from the fracture and surgical manipulation. Administering prescribed analgesia like morphine is a priority for pain management.

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Correct Answer is ["1350"]

Explanation

Rationale:

Fluid resuscitation rate using the Parkland formula:

Calculate the total fluid volume needed for the first 24 hours.

The Parkland formula: 4 mL × client weight (kg) × % TBSA burned.

Client weight = 90 kg

TBSA burned = 45%

Total fluid volume = 4 mL × 90 kg × 45 = 16,200 mL

Determine the amount of fluid to be given in the first 8 hours.

According to the Parkland formula, half of the total fluid volume is administered in the first 8 hours from the time of the burn injury.

Fluid for first 8 hours = 16,200 mL / 2

= 8,100 mL

Calculate the infusion rate for the first 8 hours.

The burn occurred at 1000. The nurse arrives at 1200. This means 2 hours have already passed since the burn occurred within the initial 8-hour period.

Remaining time in the first 8 hours = 8 hours - 2 hours

= 6 hours.

Infusion rate (mL/hour) = Fluid for remaining first 8 hours / Remaining time in first 8 hours

= 8,100 mL / 6 hours

= 1350 mL/hour.

A. Heart rate 100 beats/minute. B. Blood pressure 125/65 mm Hg. C. Heart rate 70 beats/minute. D. Blood pressure 115/70 mm Hg.

Correct Answer is A

Explanation

A. Heart rate 100 beats/minute: A compensatory increase in heart rate (tachycardia) is expected in orthostatic hypotension. It helps maintain cerebral perfusion when blood pools in the lower extremities after standing quickly.

B. Blood pressure 125/65 mm Hg: This BP shows a slight systolic increase, which is not typical after orthostatic stress. A decrease in BP, not an increase, would be expected if symptoms like dizziness are present.

C. Heart rate 70 beats/minute: A decreased heart rate is not physiologically expected when someone experiences postural hypotension. Bradycardia would worsen cerebral perfusion and is inconsistent with dizziness.

D. Blood pressure 115/70 mm Hg: This change is too minor to explain dizziness. In orthostatic hypotension, we usually expect a drop of ≥20 mm Hg systolic or ≥10 mm Hg diastolic after position change.

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Exhibits The nurse reviews the prescriptions and plans initial steps for caring for the client. Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["1350"]

Explanation

A client's most recent vital signs include heart rate 80 beats/minute and blood pressure 119/70 mm Hg. When the client reports dizziness after rising quickly, which finding should the nurse expect on reassessment?

Correct Answer is A

Explanation

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Exhibits

The nurse reviews the prescriptions and plans initial steps for caring for the client. Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.