The nurse is caring for a patient with a blood pressure of 88/50 and symptomatic. The nurse recognizes which nursing action is a priority?

Prepare for the administration of IV fluids

Administer a bolus of IV fluids

Administer Atenolol stat

Administer Nitroglycerin

Answer and Explanation

The Correct Answer is B

Choice A reason: Preparing for the administration of IV fluids is important but not as immediate as administering a bolus of IV fluids. Immediate fluid resuscitation is crucial for addressing low blood pressure and improving the patient's hemodynamic status.

Choice B reason: Administering a bolus of IV fluids is the priority nursing action for a patient with symptomatic hypotension. Rapid fluid administration helps to increase blood volume and improve blood pressure, which is essential for stabilizing the patient.

Choice C reason: Administering Atenolol, a beta-blocker, is not appropriate for a patient with hypotension. Beta-blockers can further lower blood pressure and are contraindicated in this situation.

Choice D reason: Administering Nitroglycerin is not suitable for a patient with hypotension. Nitroglycerin can cause vasodilation and further decrease blood pressure, which would worsen the patient's condition.

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Correct Answer is ["C","D"]

Explanation

Choice A reason: Mineralocorticoids are produced by the adrenal glands and regulate sodium and potassium balance, not typically associated with the symptoms of myxedema.

Choice B reason: Calcitonin is involved in calcium metabolism and is not related to the symptoms of myxedema.

Choice C reason: Thyroxine (T4) is a thyroid hormone essential for regulating metabolism. A deficiency in T4 leads to symptoms such as fatigue, cold intolerance, and myxedema.

Choice D reason: Triiodothyronine (T3) is another thyroid hormone crucial for metabolism regulation. A lack of T3, along with T4, contributes to the symptoms of myxedema.

Choice E reason: Glucocorticoids are produced by the adrenal glands and are involved in stress response and metabolism, but are not directly related to myxedema.

A. "Yes, that's why you are hospitalized." B. "Yes, but it will never happen again." C. "No, but it is necessary to monitor, control, and eliminate your chest pain." D. "No, it is normal to feel chest pain."

Correct Answer is C

Explanation

Choice A reason: Telling the client that they are hospitalized due to a heart attack when it is not the case can cause unnecessary anxiety and fear. It is important to provide accurate information and reassurance.

Choice B reason: Stating that it will never happen again is unrealistic and provides false reassurance. It is important to focus on managing the client's condition and reducing the risk of future episodes.

Choice C reason: Explaining that the client did not have a heart attack but emphasizing the importance of monitoring and managing chest pain provides accurate information and reassurance. It helps reduce the client's anxiety and provides a clear plan of action.

Choice D reason: Saying it is normal to feel chest pain without further explanation can cause confusion and anxiety. It is important to clarify that chest pain needs to be monitored and managed to prevent complications.

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The nurse is caring for a patient with a blood pressure of 88/50 and symptomatic. The nurse recognizes which nursing action is a priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with myxedema reports experiencing fatigue, cold intolerance, and swelling around the eyes and face. The nurse plans care, understanding that these clinical manifestations are caused by a lack of or diminished production of which hormones? (Select all that apply)

Correct Answer is ["C","D"]

Explanation

A client diagnosed with angina pectoris appears to be very anxious and states, "So I had a heart attack, right?" Which response should the nurse make to the client?

Correct Answer is C

Explanation

A client diagnosed with acute kidney injury has an elevated blood urea nitrogen (BUN) and is experiencing difficulty remembering information. Which interventions should the nurse implement when communicating with this client? (Select all that apply)

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