The nurse is caring for a client diagnosed with deep vein thrombosis who suddenly becomes short of breath, anxious, and restless.

The vital signs are: heart rate 130 beats/minute, respirations 42/minute, blood pressure 90/50, and pulse oximetry is 90%. An intravenous infusion of normal saline is running at 75ml/hr. The nurse elevates the head of the bed and applies nasal oxygen at 2L/min.

What action should the nurse take next?

Administer the PRN antianxiety medication.

Call the rapid response team.

Increase the intravenous infusion rate.

Prepare for mechanical ventilation.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Administering the PRN antianxiety medication is not the most appropriate next step. The client’s symptoms—shortness of breath, anxiety, restlessness, tachycardia, tachypnea, hypotension, and decreased oxygen saturation—are indicative of a potential pulmonary embolism, a life-threatening complication of deep vein thrombosis. While anxiety can be a symptom of a pulmonary embolism, treating it without addressing the underlying cause could delay necessary medical intervention.

Choice B rationale

Calling the rapid response team is the most appropriate next step. The client’s symptoms suggest a potential pulmonary embolism, a serious and life-threatening condition that requires immediate medical intervention. The rapid response team can provide the necessary urgent care.

Choice C rationale

Increasing the intravenous infusion rate is not the most appropriate next step. While hydration is important, it would not address the immediate life-threatening situation. The client’s symptoms suggest a potential pulmonary embolism, which requires immediate medical intervention.

Choice D rationale

Preparing for mechanical ventilation is not the most appropriate next step. While the client’s decreased oxygen saturation and increased respiratory rate suggest respiratory distress, the priority should be to address the potential pulmonary embolism. Mechanical ventilation may be necessary later depending on the client’s response to treatment.

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Correct Answer is A

Explanation

Choice A rationale

Consuming excessive amounts of antacids, such as TUMS, can lead to metabolic alkalosis. Antacids contain bicarbonate, which can neutralize stomach acid. However, excessive bicarbonate in the body can disrupt the acid-base balance, leading to metabolic alkalosis.

Choice B rationale

Respiratory acidosis is typically caused by conditions that result in hypoventilation, such as lung diseases or drug overdose, not by excessive antacid consumption.

Choice C rationale

Metabolic acidosis is typically caused by conditions that increase acid in the body or decrease bicarbonate, such as kidney disease or lactic acidosis, not by excessive antacid consumption.

Choice D rationale

Respiratory alkalosis is typically caused by conditions that result in hyperventilation, such as anxiety or fever, not by excessive antacid consumption.

A. Schedule and keep appointments for annual eye exams. B. Ensure adequate fluid intake to prevent kidney damage. C. Cardiac enzymes will be checked every 6 months. D. Podiatry exams are necessary every 3 months.

Correct Answer is A

Explanation

Choice A rationale

Diabetes mellitus can lead to several chronic complications, including retinopathy, which can cause blindness. Regular eye exams are crucial for early detection and treatment of diabetic retinopathy. Therefore, scheduling and keeping appointments for annual eye exams is an important part of managing diabetes.

Choice B rationale

While adequate fluid intake is generally important for overall health, it is not specifically effective in preventing kidney damage in patients with diabetes mellitus. Kidney damage in diabetes, also known as diabetic nephropathy, is caused by high blood sugar levels over time, not by dehydration.

Choice C rationale

Regular checks of cardiac enzymes are not a standard part of diabetes management. Cardiac enzymes are typically checked in the context of suspected heart disease or a heart attack, not as a routine measure in diabetes care.

Choice D rationale

While regular foot care is important in diabetes to prevent complications such as foot ulcers and infections, podiatry exams every 3 months are not typically necessary unless the patient has a history of foot problems or a high risk of foot complications.

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Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with a history of gastroesophageal reflux disease (GERD) consumes 15 TUMS antacid tablets daily. What risk does the nurse understand this patient is facing?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is educating a patient with diabetes mellitus about the chronic complications associated with the disease. What information should be included in the teaching?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is caring for a client with a heart murmur due to mitral valve disease. Where would the nurse hear the murmur the loudest?

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What clinical manifestation should the nurse assess for in a patient with uncontrolled diabetes mellitus and ketoacidosis?

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The nurse explains to a patient diagnosed with diabetes mellitus that the major benefit of frequent self-monitoring of blood glucose is that:

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