Patient Data

Exhibits

The nurse reviews the prescriptions and assessment data.

Click to indicate which interventions could help reduce symptoms if added to the plan of care. Each row must have one response option selected.

Administer 2 mg of diazepam intravenously.

Induce paralysis.

Apply cooling blankets.

Apply 1 L/min oxygen.

Ensure that the antidepressant medication is discontinued

Answer and Explanation

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

Diazepam is a benzodiazepine that can be effective in managing symptoms of serotonin syndrome, including agitation and myoclonus. It can help reduce muscle rigidity and provide sedation.

Inducing paralysis is not appropriate in this scenario. The patient’s symptoms suggest serotonin syndrome or another type of stimulant intoxication, and paralysis could worsen the situation or mask underlying symptoms.

The patient has a high fever (102°F or 38.8°C) and significant diaphoresis. Cooling blankets can help manage hyperthermia and reduce body temperature.

The patient’s oxygen saturation is 97% on room air, indicating adequate oxygenation. There is no immediate need for supplemental oxygen at this time.

If the patient is suspected to have serotonin syndrome, which can be triggered by the use of certain antidepressants (particularly SSRIs), discontinuing the offending medication is crucial.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Applying heat may be indicated later, but the first action should be to address the infiltration.

B. Documenting the delay is important but not the immediate priority.

C. Starting a new IV site is necessary for continued medication administration but should be done after addressing the infiltration.

D. Removing the infiltrated IV catheter is the first priority to prevent further tissue damage and start appropriate treatment for infiltration.

A. Assess for symmetrical chest movement. B. Obtain a portable chest x-ray to verify ETT location. C. Monitor ETT markings between 22 and 26 cm at teeth line. D. Check for capillary refill of 3 seconds or less. E. Auscultate for presence of bilateral breath sounds.

Correct Answer is ["A","B","E"]

Explanation

A. Assessing for symmetrical chest movement helps ensure that air is moving into both lungs, indicating proper placement of the ETT.

B. Obtaining a portable chest x-ray is a definitive method to verify ETT placement in the correct position within the trachea.

C. Monitoring ETT markings is useful for tracking tube displacement over time, but it does not confirm correct placement.

D. Checking capillary refill is not relevant for confirming ETT placement; it assesses peripheral circulation.

E. Auscultating for bilateral breath sounds confirms that air is reaching both lungs, which indicates correct placement of the ETT.

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Patient Data Exhibits The nurse reviews the prescriptions and assessment data. Click to indicate which interventions could help reduce symptoms if added to the plan of care. Each row must have one response option selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Before administering an IV antibiotic, the nurse observes that the skin above the client's IV site is cool, swollen, and painful to touch. Which action should the nurse implement first?

Correct Answer is D

Explanation

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

An older client with osteoarthritis reports increasing pain and stiffness in the right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of the symptoms?

A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider?

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

The adult child of an older adult client who has Parkinson's disease, calls the clinic and reports that the client has been confused for the past week. What action(s) should the nurse take? Select all that apply.

The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?

The nurse is providing dietary education to a client in end stage kidney failure who requires dialysis three times a week. Which information is important for the nurse to include about the client's daily diet?

Patient Data

Exhibits

The nurse reviews the prescriptions and assessment data.

Click to indicate which interventions could help reduce symptoms if added to the plan of care. Each row must have one response option selected.