A client is admitted to the intensive care unit (ICU) after surgical repair of an aortic abdominal aneurysm (AAA). Sodium nitroprusside is infusing for severe postoperative hypertension. Normal saline is also infusing at 50 mL/hr. When the client suddenly reports back pain, the nurse measures the client's vital signs to be a heart rate of 38 beats/minute and a blood pressure of 80/60 mm Hg. Which intervention should the nurse implement first?

Notify the rapid response team.

Discontinue nitroprusside infusion.

Increase the saline infusion rate.

Place client's head flat and feet elevated.

Answer and Explanation

The Correct Answer is B

A. Notifying the rapid response team is essential in cases of sudden hemodynamic instability, but immediate actions to stop potential causes of hypotension must be taken first. Delaying this step could worsen shock or compromise perfusion.

B. Discontinuing the nitroprusside infusion is the first priority because the client is experiencing hypotension, which may be exacerbated by ongoing vasodilation from the medication. Rapid intervention to stop the source of hypotension is critical to prevent further cardiovascular collapse and maintain organ perfusion.

C. Increasing the saline infusion rate may help restore intravascular volume, but it does not address the immediate cause of hypotension from the vasodilator. Volume expansion alone may be insufficient if nitroprusside continues to lower blood pressure.

D. Placing the client with head flat and feet elevated can temporarily improve venous return and perfusion, but this is a supportive measure and does not treat the underlying cause of sudden hypotension. Immediate discontinuation of the vasodilator takes precedence.

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Correct Answer is D

Explanation

Rationale:
A. Apply external pacing pads: Transcutaneous pacing is appropriate for symptomatic bradycardia with a pulse, not for pulseless electrical activity (PEA). In this case, the client has no pulse, so pacing will not generate effective cardiac output and should not be the first intervention.

B. Obtain blood pressure reading: During cardiac arrest, the client has no palpable pulse or measurable blood pressure. Attempting to obtain a blood pressure reading wastes valuable time that should be spent on life-saving interventions such as medication administration and high-quality CPR.

C. Insert second peripheral IV: While establishing additional IV access can be useful for administering fluids or medications, it is not the immediate priority during a pulseless event. The focus should remain on pharmacologic support and maintaining perfusion through CPR.

D. Prepare epinephrine 1 mg IV: Epinephrine is the first-line medication for PEA and asystole because it enhances myocardial contractility and increases coronary and cerebral perfusion during CPR. It should be administered as soon as possible, followed by continued chest compressions and rhythm reassessment every 2 minutes.

A. Poor cough, diaphragmatic breathing. B. Absence of sensory and motor function. C. Paraplegia. D. Intact sensory but absent motor function. E. Tetraplegia (quadriplegia).

Correct Answer is ["A","B","E"]

Explanation

Rationale:
A. Poor cough, diaphragmatic breathing: Cervical spinal cord injuries can impair innervation of the diaphragm and accessory muscles, resulting in weak cough and compromised respiratory effort. This is common with high cervical transections and can lead to respiratory complications.

B. Absence of sensory and motor function: A complete transection at the cervical level causes total loss of voluntary motor function and sensation below the level of injury. Both sensory and motor deficits are hallmark features of complete spinal cord injury.

C. Paraplegia: Paraplegia involves paralysis of the lower extremities, typically resulting from thoracic, lumbar, or sacral injuries. It is not characteristic of high cervical cord transection.

D. Intact sensory but absent motor function: This describes a condition such as anterior cord syndrome or incomplete spinal cord injury. Complete transection affects both motor and sensory pathways, so this pattern is inconsistent.

E. Tetraplegia (quadriplegia): Injury at the cervical level affects all four extremities, resulting in tetraplegia. This is a primary manifestation of complete cervical cord transection.

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Body system	Findings
Cardiovascular	Pedal pulse of 2+ or better Blood pressure of 120/74 mm Hg Capillary refill of 4 seconds in lower extremities
Neurovascular	Skin that is pale, cool to touch Pupils equal and nonresponsive to light Absence of numbness or tingling in feet
Renal Perfusion	Creatinine of 1.2 mg/dL (106 mmol/L) Client has urine output of 1,600 mL in 24 hours Decreased blood urea nitrogen (BUN) level of 9.8 mg/dL (3.50 mmol/L)

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Naxlex Comprehensive Predictor Exams

After two minutes of cardiopulmonary resuscitation, the client's electrocardiogram (ECG) displays third degree heart block with no palpable pulse. Which intervention should the nurse implement?

Correct Answer is D

Explanation

The nurse is caring for a client who is admitted with head and neck injury following a motor vehicle accident. The nurse should identify which clinical manifestation(s) are associated with a complete transection of the cervical spinal cord? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

Patient Data Exhibits Which are important to monitor in this client following the chest tube placement? Select all that apply.

Based on this strip, which is the correct interpretation of this rhythm?

A client is to receive mannitol IV for increased intracranial pressure. Which outcome may result from the use of mannitol?

The nurse is completing a head to toe assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the nurse?

A client who sustained a head injury is alert and oriented to person, place, time, and situation, moves all extremities on command, has equal muscle strength bilaterally, and pupils are reactive to light. Which action should the nurse implement next?

A client arrives to the emergency department (ED) following a motor vehicle collision. The nurse observes the client experiencing increasing dyspnea and notes absent breath sounds on the left side. Which procedure should the nurse prepare the client for?