The nurse is caring for a client with a spinal cord injury at C3. The nurse notices on the cardiac monitor a heart rate of 30 beats per minute & upon assessment of the patient, a change in mental status. What medication does the nurse anticipate will be ordered by the physician STAT?

Atropine 1mg IV push

Epinephrine 1 mg (1:10,000) IV X1

Adenosine 6 mg IV push

Milrinone 50 mcg/kg IV push

Answer and Explanation

The Correct Answer is A

A. Atropine 1 mg IV push

A C3 spinal cord injury disrupts sympathetic control, causing bradycardia. Atropine is the first-line treatment for symptomatic bradycardia.

B. Epinephrine 1 mg IV

Epinephrine is used for cardiac arrest, not initial management of bradycardia.

C. Adenosine 6 mg IV push

Adenosine is used for supraventricular tachycardia, not bradycardia.

D. Milrinone 50 mcg/kg IV push

Milrinone is an inotrope used in heart failure, not bradycardia.

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Correct Answer is C

Explanation

A. Respiratory rate 24 and bloody drainage in the NG tube

While an increased respiratory rate and bloody drainage are concerning, they may not indicate an immediate life-threatening situation compared to the other options.

B. Client is oriented to name and place but not the date

This suggests some level of confusion or altered mental status, which is important but not necessarily an immediate threat.

C. Blood pressure 40/48 and urine output of 24 mL/hour

This indicates severe hypotension and inadequate perfusion, which are signs of ongoing shock and possibly continued internal bleeding. Immediate intervention is critical.

D. Hypo-active bowel sounds and tachycardia

Hypo-active bowel sounds and tachycardia are concerning and suggestive of shock, but they are not as immediately life-threatening as severely low blood pressure and low urine output.

A. A- B. 0+ C. AB- D. A+ E. 0-

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

Explanation

A. A
Patients with A- blood type have A antigens on their red blood cells and do not have the Rh factor (negative). They can receive A- blood because it has the same antigens and Rh factor, making it a perfect match.

B. O+
Rh-negative clients cannot receive Rh-positive blood, as it may trigger an immune reaction.

C. AB-
Type AB blood contains A and B antigens, which A- individuals do not naturally have, increasing the risk of a transfusion reaction.

D. A+
A Rh-negative (A-) client cannot receive Rh-positive (A+) blood due to the risk of Rh sensitization.

E. O-
O- blood is the universal donor for red blood cells, meaning it contains no A, B, or Rh antigens, making it safe for an A- recipient.

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The nurse is caring for a client with a spinal cord injury at C3. The nurse notices on the cardiac monitor a heart rate of 30 beats per minute & upon assessment of the patient, a change in mental status. What medication does the nurse anticipate will be ordered by the physician STAT?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse is preparing to administer a unit of packed red blood cells (PRBC's) to a patient whose blood type is A- (negative). The nurse knows that this patient can receive transfusions from which blood types? (Select All that Apply)

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

Explanation

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The nurse is performing an assessment on a client. How would the nurse best evaluate improvement or deterioration in the neurologic status?

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