A disoriented and agitated patient comes to the emergency department and admits using methamphetamine. Vital signs are blood pressure 164/94 mm Hg. heart rate 136 beats/min and irregular, and respirations 32 breaths/min. Which action by the nurse is most important?

Reorient the patient at frequent intervals.

Monitor the patient's electrocardiogram.

Keep the patient in a quiet and darkened room.

Obtain a health history including prior drug use.

Answer and Explanation

The Correct Answer is B

B. Methamphetamine use can cause significant cardiovascular effects, including tachycardia, hypertension, and arrhythmias. Given the patient's presentation with an irregular heart rate and tachycardia, continuous cardiac monitoring through an ECG is essential to assess for any life-threatening arrhythmias or other cardiac complications.

A. Reorientation is important for patients who are disoriented, but in the case of a patient who has admitted to using methamphetamine and is exhibiting signs of agitation and tachycardia, the priority is to ensure the patient's safety and stabilize their condition.

C. While providing a calm environment is beneficial for patients who are agitated, it is not the most important action in this scenario.

D. Obtaining a comprehensive health history, including prior drug use, is important for understanding the patient's background and potential risk factors. However, in this acute situation where the patient is disoriented, agitated, and exhibiting signs of cardiovascular distress, the priority is to address the immediate medical needs and stabilize the patient's condition.

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

Explanation

A. Administering medication at the right time helps maintain therapeutic drug levels in the patient's system and ensures optimal treatment outcomes.

B. This means administering the correct medication to the patient as prescribed by the healthcare provider. It's crucial to verify the medication name, strength, and dosage form to prevent medication errors and adverse drug reactions.

C. It's essential to double-check the dose calculation and verify it against the prescription to prevent medication errors, especially with high-risk medications.

E. This means administering the medication to the correct patient. It's essential to verify the patient's identity using at least two patient identifiers (such as name and date of birth) before administering any medication to ensure it is being given to the intended recipient.

D. The color of medication is not typically considered one of the medication rights. While certain medications may have specific color coding for identification purposes, relying solely on color to identify a medication can be misleading and increase the risk of errors.

A. Malignant hypothermia B. Pulmonary embolism C. Fat embolism syndrome D. Acute compartment syndrome

Correct Answer is D

Explanation

D. Fractures, crush injuries, or tight casts can lead to compartment syndrome. Symptoms include severe pain, swelling, numbness or tingling, and decreased sensation or function of the affected limb.

Increasing edema in the calf is a hallmark manifestation of acute compartment syndrome and indicates a worsening of the condition.

A. Malignant hyperthermia is a rare but life-threatening complication that can occur in response to certain medications used during anesthesia. Edema in the calf is not a manifestation of malignant hyperthermia.

B. Pulmonary embolism occurs when a blood clot travels to the lungs and blocks blood flow. While pulmonary embolism can cause symptoms such as chest pain, shortness of breath, and cough, edema in the calf is not a typical manifestation of this condition.

C. Fat embolism syndrome occurs when fat globules are released into the bloodstream, often after long bone fractures or orthopedic procedures. Increasing edema in the calf is not a characteristic manifestation of fat embolism syndrome.

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A disoriented and agitated patient comes to the emergency department and admits using methamphetamine. Vital signs are blood pressure 164/94 mm Hg. heart rate 136 beats/min and irregular, and respirations 32 breaths/min. Which action by the nurse is most important?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following statements accurately describe the medication rights? (Select All that Apply.)

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

Explanation

A nurse notes increasing edema in the calf of a client who has multiple fractures of the leg. The nurse should recognize that increasing edema is a manifestation of which of the following complications?

Correct Answer is D

Explanation

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A disoriented and agitated patient comes to the emergency department and admits using methamphetamine. Vital signs are blood pressure 164/94 mm Hg. heart rate 136 beats/min and irregular, and respirations 32 breaths/min. Which action by the nurse is most important?

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