The healthcare provider has prescribed intravenous (IV) lorazepam for the patient in status epilepticus. During administration, which is the priority assessment by the nurse?

Drug dependence

Cardiac rhythm

Pulse oximetry

Pain level

Answer and Explanation

The Correct Answer is C

A. While drug dependence can be a concern with long-term use, it is not the immediate priority in an emergency setting where the goal is to stabilize the patient in status epilepticus.

B. Cardiac rhythm monitoring is important when administering certain medications, but lorazepam primarily affects the central nervous system and respiratory system, making oxygen saturation monitoring more critical.

C. Pulse oximetry is the priority assessment as IV lorazepam can depress the respiratory system, leading to hypoxia. Monitoring oxygen saturation helps ensure the patient maintains adequate respiratory function during administration.

D. Assessing pain is important in patient care, but it is not the priority in managing a patient in status epilepticus, where stabilization is essential.

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Correct Answer is B

Explanation

A. Sharing eating utensils does not transmit HIV, as the virus is not spread through saliva.

B. Sharing razors is a high-risk activity for transmitting HIV because it can involve direct blood-to-blood contact if the razor causes cuts.

C. HIV transmission through kissing is highly unlikely due to low levels of the virus in saliva.

D. HIV cannot be spread through shared toilets, as the virus does not survive on surfaces and is not spread through casual contact.

A. Encourage the patient to cough to expectorate secretions B. Elevate the head of the bed to 30-45 degrees C. Stimulate the patient with active range of motion exercises D. Perform serial neurologic assessments while hospitalized E. Contact the healthcare provider if the ICP is sustained between 30-40mmHg

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

Explanation

A. Coughing can increase ICP by increasing intrathoracic pressure and should be minimized in patients with head injuries.

B. Elevating the head of the bed to 30-45 degrees promotes venous drainage from the head, reducing ICP.

C. Active stimulation can increase ICP and is generally avoided in patients with acute head injuries.

D. Serial neurologic assessments help monitor any changes in the patient’s condition and ICP, allowing for timely intervention.

E. Sustained ICP levels between 30-40 mmHg are significantly elevated and require immediate communication with the healthcare provider, as they are above the normal range and could lead to further complications

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The healthcare provider has prescribed intravenous (IV) lorazepam for the patient in status epilepticus. During administration, which is the priority assessment by the nurse?

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Naxlex Comprehensive Predictor Exams

The nurse teaching a patient who is diagnosed with human immunodeficiency virus (HIV), would include which information regarding an activity that has the highest potential to spread the disease to relatives or friends in a household?

Correct Answer is B

Explanation

The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for the patient with an acute head injury. Which action(s) should the nurse take to achieve this goal? (SELECT ALL THAT APPLY)

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

Explanation

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