How it Works
Try Naxlex NCLEX-RN (Free-Trial)

A nurse in a medical-surgical unit is caring for a clent

Exhibits

Complete the following sentence by using the lists of options.

The nurse should first address the

followed by the client .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Rationale for Correct Choices:

  • Pain level: The client reports severe epigastric pain radiating to the back with a pain score increasing from 7 to 9 out of 10. Managing this acute pain is critical to improve the client's comfort, reduce stress response, and help prevent complications such as respiratory distress caused by shallow breathing due to pain.
  • Blood pressure: The client’s blood pressure has dropped to 86/48 mm Hg, indicating hypotension that can lead to poor tissue perfusion and shock. After addressing pain, stabilizing blood pressure is essential to prevent organ dysfunction and maintain hemodynamic stability.

Rationale for Incorrect Choices:

  • Lung sounds: Although diminished breath sounds and rhonchi are concerning and may indicate complications, immediate pain control can improve respiratory effort and oxygenation before focusing on lung sounds.
  • Bowel sounds: Hypoactive bowel sounds are common in pancreatitis but are less urgent than pain and hypotension in acute care.
  • Temperature: Fever suggests infection or inflammation but is a lower priority compared to controlling pain and stabilizing blood pressure.
  • Blood glucose level:  Elevated glucose requires monitoring but is less urgent than the client’s pain and hypotension in the acute phase.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is D

Explanation

Rationale:

A. Insert an indwelling urinary catheter: While important for monitoring urine output and renal perfusion, catheter insertion is not the immediate priority in a trauma situation. It should be done after vascular access is secured and life-threatening conditions are addressed.

B. Administer packed RBCs: Blood transfusion is critical for managing hemorrhagic shock, but it cannot be initiated until a large-bore IV is placed. Vascular access is necessary before any fluid or blood product administration.

C. Obtain a specimen for ABG analysis: ABGs provide valuable data on oxygenation and acid-base balance but are diagnostic rather than life-sustaining. This step is less urgent than establishing IV access for fluid resuscitation or transfusion.

D. Place a large-bore IV catheter in an upper extremity: In trauma care, rapid IV access is the top priority to allow fluid and blood product resuscitation. A large-bore catheter ensures high-volume administration, which is essential in potential hemorrhagic shock.

Correct Answer is C

Explanation

Rationale:

A. Tinnitus: Tinnitus is not a known or common adverse effect of clozapine. While it may indicate another condition, it does not require immediate reporting in the context of clozapine therapy.

B. Dizziness: Dizziness can occur due to clozapine’s hypotensive effects, especially when initiating therapy. It is usually self-limiting and managed symptomatically unless it worsens or affects safety.

C. Sore throat: A sore throat can signal the onset of agranulocytosis, a life-threatening side effect of clozapine marked by a dangerously low white blood cell count. It must be reported immediately for prompt blood count evaluation.

D. Diaphoresis: Diaphoresis may occur with many medications and is not specific to clozapine toxicity or serious adverse effects. It typically does not warrant immediate reporting unless severe or part of a broader concerning symptom complex.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register