The nurse receives new orders for multiple clients. Which order should be the nurse's priority?

Nitroglycerin 0.4 mg sublingually STAT for the client experiencing chest pain.

Lorazepam 2 mg IV now for the client experiencing restlessness and picking at tubing.

Morphine sulfate 4 mg IV now for the client experiencing incisional pain.

One unit packed red blood cells STAT for the client with hemoglobin of 9.5 g/dL.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Administering Nitroglycerin 0.4 mg sublingually STAT for the client experiencing chest pain should be the nurse's priority because chest pain can be indicative of a myocardial infarction (heart attack), which is a medical emergency. Quick administration of Nitroglycerin can help to relieve chest pain, improve blood flow to the heart, and prevent further cardiac damage.

Choice B reason:

While administering Lorazepam 2 mg IV for the client experiencing restlessness and picking at tubing is important for patient safety and comfort, it is not as urgent as addressing potential cardiac issues indicated by chest pain.

Choice C reason:

Administering Morphine sulfate 4 mg IV for incisional pain management is necessary for the patient’s comfort and pain control but is not as critical as treating potential life-threatening chest pain.

Choice D reason:

Administering one unit of packed red blood cells STAT for the client with a hemoglobin of 9.5 g/dL is important but does not take precedence over the immediate risk of a myocardial infarction. The hemoglobin level, while low, is not immediately life-threatening compared to the chest pain scenario.

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Correct Answer is A

Explanation

Choice A reason:

The patient coughing is the most likely cause of the high pressure alarm on a mechanical ventilator. Coughing can increase airway resistance and pressure, triggering the alarm. This is a common occurrence and should be addressed by assessing the patient's need for suctioning or other interventions to relieve the cough.

Choice B reason:

An endotracheal tube (ETT) cuff leak would typically cause a low pressure alarm, not a high pressure alarm. A cuff leak results in a loss of pressure within the ventilator circuit, leading to insufficient ventilation and a different alarm response.

Choice C reason:

If the ventilator tubing becomes disconnected, it would result in a low pressure alarm due to the loss of circuit integrity. A disconnection is a serious issue that needs immediate correction but does not cause high pressure alarms.

Choice D reason:

The patient's complaint of a headache does not directly relate to a high pressure alarm on the ventilator. While patient discomfort should always be addressed, it is not the most likely cause of the alarm in this scenario.

A. Young adults ages 12-20. B. Young men ages 16-30. C. Children ages 2-15. D. Elderly people ages 60 and up.

Correct Answer is B

Explanation

Choice A reason:

Young adults ages 12-20 are at risk for spinal cord injuries due to sports and recreational activities. However, the highest risk group for spinal cord injuries, particularly from activities such as motor vehicle accidents and risky behaviors, is young men ages 16-30.

Choice B reason:

Young men ages 16-30 are the highest risk group for spinal cord injuries. This population is more likely to engage in high-risk activities such as driving, contact sports, and recreational activities that can lead to spinal cord injuries. Therefore, they would benefit most from targeted prevention education.

Choice C reason:

Children ages 2-15 are at risk for spinal cord injuries, particularly from falls and accidents. However, their risk is lower compared to the young adult male population. Education for this group is important but not as critical as for young men.

Choice D reason:

Elderly people ages 60 and up are at risk for spinal cord injuries, primarily from falls. While prevention education is important for this group, they are not the highest risk population compared to young men ages 16-30.

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The nurse receives new orders for multiple clients. Which order should be the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient who is on mechanical ventilation and the high pressure alarm is sounding. Which of the following is the most likely cause?

Correct Answer is A

Explanation

As a community health nurse, you are planning to conduct an education session on prevention strategies for spinal cord injuries. Which population would benefit most from this education?

Correct Answer is B

Explanation

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