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A nurse in the emergency department is assisting in the care of a client.

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Nurses Notes

1630:

Called to client's room by emergency call bell. Client is alert and oriented to person, place, and time. Client is short of breath, intercostal retractions visible. Wheezing auscultated throughout lung fields, Diffuse, raised rash present on trunk. Abdomen soft, nontender

Vital Signs

1630:

Temperature 38.3°C (101°F)

Heart rate 110/min

Respiratory rate 30/min

Blood pressure 90/55 mmHg

Oxygen saturation 91% on room air

Client is short of breath

intercostal retractions visible

Wheezing auscultated throughout lung fields

Diffuse, raised rash present on trunk

Respiratory rate 30/min

Blood pressure 90/55 mmHg

Oxygen saturation 91% on room air

Temperature 38.3°C (101°F)

Client is alert and oriented to person, place, and time.

Heart rate 110/min

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F","G"]

Shortness of breath. The client is experiencing respiratory distress, which could indicate a severe allergic reaction (anaphylaxis). Immediate intervention is needed to prevent airway compromise and respiratory failure.
Intercostal retractions. Retractions occur when breathing is labored, suggesting airway obstruction or bronchoconstriction. This is a sign of worsening respiratory distress, requiring urgent medical attention.
Wheezing auscultated throughout lung fields. Wheezing suggests bronchospasm, which is common in anaphylaxis and asthma attacks. The presence of diffuse wheezing indicates that the airways are narrowing, making breathing more difficult.
Diffuse, raised rash present on trunk. A new-onset rash following antibiotic administration raises suspicion for anaphylaxis or a severe allergic reaction. Immediate treatment with antihistamines and corticosteroids may be required.
Respiratory rate 30/min. The increased respiratory rate indicates that the client is compensating for airway constriction and hypoxia. This is an early warning sign of impending respiratory failure if not treated promptly.
Blood pressure 90/55 mmHg. The drop in blood pressure suggests anaphylactic shock, where vasodilation and fluid leakage from capillaries lead to hypotension. Immediate administration of epinephrine is necessary to prevent cardiovascular collapse.
Oxygen saturation 91% on room air. A decrease in oxygen saturation indicates impaired gas exchange, likely due to airway swelling and bronchospasm. Supplemental oxygen therapy should be provided to prevent further desaturation.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is ["3"]

Explanation

Convert pounds to kilograms:

Conversion factor: 1 kg = 2.2 lb

66 lb / 2.2 lb/kg = 30 kg

Calculate the dose to administer:

Dose (mg) = Weight (kg) × Dosage (mg/kg)

=30 kg × 0.1 mg/kg

= 3 mg

A. Insert the needle at a 45° or 90° angle. B. Hold the skin taut during administration C. Massage the injection site after administrating the enoxaparin. D. Use a 4 cm (1.6in) needle

Correct Answer is A

Explanation

A. Insert the needle at a 45° or 90° angle. Enoxaparin is administered subcutaneously, and subcutaneous injections should be given at either a 45° or 90° angle, depending on the client’s body size and the amount of subcutaneous tissue available. A 90° angle is typically used for clients with more subcutaneous tissue, while a 45° angle is appropriate for those with less.

B. Hold the skin taut during administration. When giving subcutaneous injections, the skin should be gently pinched rather than held taut. Pinching helps ensure the medication is delivered into the fatty tissue rather than the muscle, reducing the risk of intramuscular injection, which can increase bleeding risk with anticoagulants like enoxaparin.

C. Massage the injection site after administering the enoxaparin. Massaging the injection site is contraindicated because it can cause tissue irritation, bruising, and increased risk of bleeding. Instead, gentle pressure may be applied with a gauze pad if necessary to minimize bleeding.

D. Use a 4 cm (1.6 in) needle. A needle length of 4 cm (1.6 inches) is too long for a subcutaneous injection and increases the risk of intramuscular administration, which could lead to increased bleeding and bruising. The recommended needle length for subcutaneous injections is typically ½ inch (1.25 cm) to ⅝ inch (1.6 cm) to ensure proper medication delivery.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer morphine 0.1 mg/kg IM to a school-age child who weighs 66 lb. What is the dose that the nurse should administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["3"]

Explanation

A nurse is preparing to administer enoxaparin 5,000 units subcutaneous to a client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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