The nurse is continuing to care for the client.
Vital Signs.
Day 1, 0900:. Temperature (oral) 36.9° C (98.4° F). Heart rate 72/min.
Respiratory rate 16/min.
BP 162/112 mm Hg. Day 1, 0930:. Oxygen saturation 97% on room air.
Temperature (oral) 37.1° C (98.8° F). Heart rate 84/min.
Respiratory rate 18/min.
BP 166/110 mm Hg. Oxygen saturation 99% on room air.
Drag words from the choices below to fill in each blank in the following.
sentence.
The client is at greatest risk for developing Target 1 and Target 2. Conditions.

Placental abruption.

Cervical insufficiency.

Seizures.

Hypoglycemia.

Heart failure.

Answer and Explanation

Correct Answer : C,E

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Correct Answer is B

Explanation

The correct answer is B. The nurse should encourage the family to express their feelings of loss and provide emotional support and comfort during this difficult time. The nurse should also respect their cultural and religious beliefs and practices regarding death and dying, and allow them to spend as much time as they need with their loved one's body, unless there are infection control issues or legal requirements that prevent it. The other options are incorrect because they are insensitive and disrespectful to the family's needs and wishes.

A. Keep calcium gluconate at the client's bedside. B. Attach an inline filter to the IV tubing. C. Protect the IV bag from exposure to light. D. Monitor blood pressure every 2 hr.

Correct Answer is C

Explanation

Answer is: c. Protect the IV bag from exposure to light.

Explanation: Nitroprusside degrades when exposed to light, so the nurse should protect the IV bag from light exposure to maintain the medication's potency and effectiveness in treating the client's severe hypertension.

Choice a. is wrong because calcium gluconate is used as an antidote for magnesium sulfate toxicity. Although it may be kept on hand in some facilities, it is not directly related to the administration of nitroprusside.

Choice b. is wrong because attaching an inline filter is not necessary when administering nitroprusside. It is more relevant for medications that require filtration, such as certain chemotherapeutic agents.

Choice d. is wrong because monitoring blood pressure every 2 hours is not frequent enough for a client receiving nitroprusside. The nurse should monitor the client's blood pressure more frequently, such as every 5 to 15 minutes, depending on facility policies and the client's condition.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for the family of a client who recently died. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse is assessing a client who has type 1 diabetes mellitus and was administered insulin lispro 1 hr ago.Which of the following manifestations indicates that the client might be experiencing hypoglycemia?

A nurse in a prenatal clinic is teaching a client about nonpharmacological pain management during labor. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?

A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu.The nurse should recognize which of the following findings as a potential contraindication for using lavender?

A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client's coccyx and abrasions around both wrists. Which of the following actions should the nurse take to address suspicions of elder abuse?

A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?

A nurse on a medical-surgical unit is planning care for four clients. The nurse should plan to use sterile gloves when performing which of the following procedures?

A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets 20 minutes ago. The client is lethargic and has a respiratory rate of 10/min. After securing the client's airway and initiating an IV, which of the following actions should the nurse take next?