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.

Nursing Test Bank

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Correct Answer is A

Explanation

A. Initiate IV fluid replacement is the highest priority intervention. HHS is characterized by severe dehydration due to osmotic diuresis resulting from hyperglycemia. IV fluid replacement is essential to correct dehydration and restore intravascular volume, which can help improve tissue perfusion and prevent further complications.
B. Monitoring urinary output is important in assessing renal function and response to fluid replacement therapy. However, it is not the highest priority intervention.
C. While insulin therapy is an essential part of managing hyperglycemia in HHS, it is not the highest priority intervention at the immediate onset of HHS.

D. Patient education about the manifestations and management of HHS is important for long-term management and prevention of recurrence. However, it is not the highest priority when the client is experiencing an acute episode of HHS.

A. Distended jugular veins B. Increased blood pressure C. Decreased blood pressure D. Pitting, dependent edema

Correct Answer is C

Explanation

Dehydration can lead to a decrease in blood volume and subsequent hypotension (low blood pressure) as the body tries to conserve fluid.

A, B, D are features of fluid overload.

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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 caring for a client who has a new onset of hyperglycemic hyperosmolar state (HHS). Which of the following interventions by the nurse is the highest priority?

Correct Answer is A

Explanation

A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?

Correct Answer is C

Explanation

A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?

A nurse is planning to withdraw medication from an ampule to prepare for an injection. Which of the following actions should the nurse plan to take?

A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following nursing actions are appropriate? (Select all that apply.)

A nurse is planning care for a client who has a cervical spine injury and has a halo traction device in place. Which of the following actions should the nurse plan to take?

A nurse is caring for a client who has cervical cancer and is receiving brachytherapy. Which of the following actions should the nurse take?

A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection?

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.