The nurse is reviewing the client's medical record.

Exhibits

For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Metoprolol 15 mg IV bolus

Oxygen at 2 L/min via nasal cannula

Draw electrolytes along with Hgb and Hct

Morphine 6 mg IV bolus every 3 hr as needed for pain

Nitroglycerin 0.5 mg SL now may repeat every 5 min up to 3 doses

Obtain daily weight

Atropine 0.5 mg IV bolus every 5 min up to 2 mg if heart rate drops below 60

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"A"}}

The client's record indicate that they are experiencing a myocardial infarction due to the elevated markers of inflammation, cardiac biomarkers and typical ECG findings.

Management of myocardial infarction includes oxygen supplementation, nitroglycerin, morphine sulphate, beta blocker such as metoprolol and aspirin/clopidogrel

Among the triggers of myocardial infarction can be cardiac dysrhythmias. This can be caused by electrolytes disturbances and hence the need to draw electrolytes.

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Correct Answer is C

Explanation

C. Stridor is a high-pitched, crowing sound that occurs during inspiration and indicates upper airway obstruction. Stridor following extubation is a concerning finding and requires immediate intervention to ensure adequate airway patency and prevent respiratory compromise. The nurse should notify the healthcare provider immediately and be prepared to provide interventions such as airway suctioning, supplemental oxygen, or reintubation if necessary.

A. While a sore throat is a common complaint after extubation due to irritation from the endotracheal tube, it does not typically require immediate intervention unless it is severe or accompanied by other concerning symptoms. The nurse should provide comfort measures and monitor for worsening symptoms.
B. An SPO2 of 92% is within normal rage and requires no immediate intervention.
D. While rhonchi may require intervention, they are not typically as immediately concerning as stridor, which indicates upper airway obstruction.

A. Hypertension B. 2+ edema C. Crackles in lungs D. Tachycardia

Correct Answer is D

Explanation

D. Increased heart rate (tachycardia) is a common manifestation of bleeding. The body compensates for blood loss by increasing the heart rate to maintain blood flow to vital organs
A. Typically, bleeding would cause a decrease in blood pressure rather than hypertension. High blood pressure could indicate other issues like pain or anxiety
B. Edema is not typically a direct manifestation of bleeding. It could indicate fluid overload, a common complication post-surgery, but not necessarily indicative of bleeding.
C. Crackles in lungs could suggest fluid overload or pulmonary edema but not related to bleeding.

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The nurse is reviewing the client's medical record. Exhibits For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client following extubation from a Ventilator. For which of the following findings should the nurse intervene immediately?

Correct Answer is C

Explanation

A nurse is caring for a client who is 3 hr postoperative. Which of the following findings should the nurse understand is a manifestation of bleeding?

Correct Answer is D

Explanation

A nurse is assessing a client who is postoperative following an open reduction and internal fixation (ORIF) of the femur. Which of the following assessment should be the nurse's priority?

A nurse is planning care for a client who has a new diagnosis of acute pancreatitis. Which of the following interventions should the nurse include in the plan of care?

A nurse is caring for a client who has systemic lupus erythematosus. During assessment, which of the following should the nurse expect to find?

A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft?

A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Exhibits The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up.

A nurse is taking an admission history from a client who reports Raynaud's disease. Which of the following assessment findings should the nurse identify as a potential trigger for exacerbations of Raynaud's?

A nurse is assessing a client who is receiving morphine for pain and has a respiratory rate of 8/min and a blood pressure of 80/40 mm Hg. Which of the following medications should the nurse administer?

The nurse is reviewing the client's medical record.

Exhibits

For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.