On the first day at 1830, certain medical procedures were initiated for the patient.
Which of the following procedures were likely to have been initiated based on the patient’s condition?

Initiation of peripheral IV access

X-ray of left shoulder and right knee, STAT

Computed tomography (CT) of brain, STAT

Administration of pain medication .

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale

Initiation of peripheral IV access is a common procedure in the emergency department for patients who have experienced a fall. This allows for the administration of fluids and medications as needed.

Choice B rationale

An X-ray of the left shoulder and right knee would likely be ordered given the patient’s report of pain in his left shoulder after the fall. This would help to identify any fractures or other injuries.

Choice C rationale

A CT scan of the brain may not be necessary in this case, unless the patient was experiencing symptoms such as confusion, loss of consciousness, or other neurological signs following the fall.

Choice D rationale

Administration of pain medication would likely be initiated based on the patient’s report of pain.

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Correct Answer is A

Explanation

Choice A rationale

In a patient with a recent exacerbation of heart failure who is feeling uncomfortable and anxious, with a sensation of flopping in the chest, the rhythm of the apical pulse should be prioritized. This is because changes in heart rhythm can indicate worsening heart failure or other serious cardiac conditions.

Choice B rationale

While the volume of pedal pulses can provide information about peripheral circulation, it is not as immediately relevant as the rhythm of the apical pulse in a patient with heart failure experiencing discomfort and anxiety.

Choice C rationale

The degree of skin elasticity can provide information about hydration status, but it is not as immediately relevant as the rhythm of the apical pulse in a patient with heart failure experiencing discomfort and anxiety.

Choice D rationale

The length of capillary refill can provide information about peripheral circulation and overall cardiovascular status, but it is not as immediately relevant as the rhythm of the apical pulse in a patient with heart failure experiencing discomfort and anxiety.

A. Keep the infant home from daycare for the next two days. B. Apply a cool pack to the injection site to reduce discomfort. C. Administer children’s aspirin to help prevent inflammation. D. Any level of fever is serious and should be reported right away.

Correct Answer is B

Explanation

Choice A rationale

Keeping the infant home from daycare for the next two days after vaccination is not necessary unless the child is showing signs of serious side effects, which are rare. Most vaccines have mild side effects such as soreness at the injection site or a mild fever, which should not interfere with the child’s daily activities.

Choice B rationale

Applying a cool, damp cloth or a cool pack to the injection site can help reduce redness, soreness, and/or swelling. This is a common practice recommended by healthcare professionals to alleviate discomfort after vaccination.

Choice C rationale

It is not recommended to administer aspirin to children due to the risk of Reye’s syndrome, a rare but serious condition that can affect the liver and brain. Instead, if the child is uncomfortable or has a fever, parents can consult with a healthcare provider about giving a non-aspirin pain reliever.

Choice D rationale

While any level of fever after vaccination should be monitored, it is not always serious and should not cause panic. Fevers are a common side effect of vaccinations and are usually a sign that the body is building protection against the virus or bacteria in the vaccine. However, if a high fever persists or the child shows signs of an allergic reaction, parents should contact a healthcare provider immediately.

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On the first day at 1830, certain medical procedures were initiated for the patient.Which of the following procedures were likely to have been initiated based on the patient’s condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with a recent exacerbation of heart failure is feeling uncomfortable and anxious, with a sensation of flopping in the chest.While waiting for an electrocardiogram (ECG), which assessment should the nurse prioritize?

Correct Answer is A

Explanation

A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines.Which instruction should the nurse provide the parent about care of the infant after the injections?

Correct Answer is B

Explanation

A newly recruited unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs.What intervention should the home health nurse implement to ensure adequate care for all clients?

Exhibits Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? Select all that apply.

While changing a postoperative patient’s dressing, the nurse notices purulent drainage at the site.Before reporting this to the healthcare provider, which of the patient’s lab values should the nurse check?

A patient has been admitted to the intensive care unit (ICU) with a spinal cord injury following a motor vehicle accident.Who should be contacted to manage the progression of the patient’s care?

Exhibits For each statement, specify if the client has an understanding or no understanding of asthma triggers. Each row must have one option selected.

A patient with primary hypothyroidism is showing early signs of myxedema coma. In what order should the nurse perform the following assessments? (Rank the first action at the top with the remainder in descending order.)

On the first day at 1830, certain medical procedures were initiated for the patient.
Which of the following procedures were likely to have been initiated based on the patient’s condition?