The nurse receives information about the assigned patients during shift report.
Which patient would the nurse assess first?

A patient who reports dizziness with a blood pressure (BP) of 150/92 mm Hg.

A patient who reports a severe headache and has begun vomiting.

A patient with a hip fracture who reports a pain level of 2 on a 1-to-10 scale.

A patient who received an angiotensin-converting enzyme (ACE) inhibitor 30 minutes previously and reports fatigue.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Dizziness with a blood pressure of 150/92 mm Hg indicates hypertension, but it is not an immediate life-threatening condition requiring urgent assessment compared to a severe headache and vomiting.

Choice B rationale:

A severe headache and vomiting could be indicative of a serious neurological condition such as a stroke, intracranial bleeding, or increased intracranial pressure. This patient needs urgent assessment and intervention to prevent potential complications.

Choice C rationale:

A hip fracture with a pain level of 2 on a 1-to-10 scale suggests pain but is not immediately life-threatening compared to symptoms like severe headache and vomiting.

Choice D rationale:

Fatigue after receiving an ACE inhibitor is a common side effect and, while important to monitor, does not pose an immediate threat compared to the symptoms of severe headache and vomiting.

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Correct Answer is B

Explanation

Choice A rationale:

Methotrexate is a medication used for cancer and autoimmune diseases. It does not chelate iron and is not used to treat iron overload conditions like hemochromatosis.

Choice B rationale:

Deferoxamine is an iron chelating agent used to treat iron overload conditions like hemochromatosis. It binds to excess iron and promotes its excretion from the body, preventing complications such as organ damage.

Choice C rationale:

Ferrous gluconate is an iron supplement used to treat iron deficiency anemia. It would not be appropriate for a patient with hemochromatosis, a condition characterized by iron overload.

Choice D rationale:

Iron dextran complex is another form of intravenous iron used to treat iron deficiency anemia. It is not indicated for treating iron overload conditions like hemochromatosis.

A. Metabolic acidosis. B. Metabolic alkalosis. C. Respiratory acidosis. D. Respiratory alkalosis.

Correct Answer is B

Explanation

Choice A rationale:

Metabolic acidosis is characterized by a low pH (<7.35) and a low bicarbonate level (<22 mEq/L) The given arterial blood gas (ABG) values indicate a pH of 7.48 (which is alkalotic), a PaCO2 of 38 (within the normal range of 35-45 mm Hg), and an HCO3- of 30 (which is elevated) These values indicate metabolic alkalosis, not metabolic acidosis.

Choice B rationale:

Metabolic alkalosis is characterized by a high pH (>7.45) and an elevated bicarbonate level (>26 mEq/L) The given ABG values indicate a pH of 7.48 (which is alkalotic) and an elevated HCO3- of 30, indicating metabolic alkalosis. This condition can result from excessive loss of acids (e.g., vomiting) or excessive intake of bicarbonate or alkali substances.

Choice C rationale:

Respiratory acidosis is characterized by a low pH (<7.35) and a high PaCO2 (>45 mm Hg) The given ABG values indicate a normal pH of 7.48 and a PaCO2 of 38 (within the normal range), ruling out respiratory acidosis.

Choice D rationale:

Respiratory alkalosis is characterized by a high pH (>7.45) and a low PaCO2 (<35 mm Hg) The given ABG values indicate a pH of 7.48 (which is alkalotic) and a PaCO2 of 38 (within the normal range), ruling out respiratory alkalosis.

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The nurse receives information about the assigned patients during shift report.Which patient would the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with thalassemia major who is receiving a blood transfusion shows signs of hemochromatosis.The nurse anticipates a prescription for which medication?

Correct Answer is B

Explanation

A patient's arterial blood gas (ABG) values include a pH of 7.48, a PaCO2 of 38, and an HCO3- of 30. Around which acid-base imbalance would the nurse plan the patient's care?

Correct Answer is B

Explanation

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Which laboratory report finding would support the nurse's conclusion that a patient has thalassemia major? Select all that apply.One, some, or all responses may be correct.

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The nurse receives information about the assigned patients during shift report.
Which patient would the nurse assess first?