A nurse is assessing a client who is experiencing profuse vomiting.

Upon admission, the client's vital signs were within the expected reference range, but now the client's blood pressure is 86/58 mm Hg, his pulse is 114/min and weak, and his respiratory rate is 27/min.

The client appears restless and anxious and states that he thinks he is dying.

Which of the following actions should the nurse take first?

Administer a vasoconstrictor.

Increase the IV infusion rate.

Elevate the client's feet.

Initiate oxygen therapy.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Administering a vasoconstrictor is a potential intervention for shock but it is not the first action. The client's hypotension and tachycardia are indicative of hypovolemic shock due to profuse vomiting, leading to fluid loss. The body's initial compensatory mechanism involves vasoconstriction to maintain blood pressure, so further constriction without addressing the volume deficit can worsen tissue perfusion.

Choice B rationale

The client is exhibiting signs of hypovolemic shock, including a low blood pressure of 86/58 mmHg, a high pulse of 114/min, and a high respiratory rate of 27/min. These are physiological compensations for reduced circulating blood volume. Increasing the intravenous infusion rate directly addresses the primary problem by rapidly replacing lost fluid volume, thereby increasing preload, stroke volume, cardiac output, and ultimately, blood pressure.

Choice C rationale

Elevating the client's feet can temporarily increase venous return to the heart and improve blood pressure. However, this is a passive measure that does not address the underlying fluid deficit causing the hypovolemic shock. It is a helpful adjunctive action but is not the definitive first-line intervention required to correct the circulatory collapse in this scenario.

Choice D rationale

Initiating oxygen therapy is a supportive measure for shock because it helps improve tissue oxygenation, which is compromised due to poor perfusion. While beneficial, it does not correct the root cause of the shock, which is the lack of circulating fluid volume. The most immediate and life-saving intervention is to restore fluid volume to improve cardiac output and blood pressure

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Correct Answer is C

Explanation

Choice A rationale

Drowsiness is a symptom of hypothyroidism, not hyperthyroidism (thyrotoxicosis). Levothyroxine is a synthetic thyroid hormone used to treat hypothyroidism. An overdose or excessive dose of this medication would lead to symptoms of hyperthyroidism, which is the opposite of drowsiness. Instead, clients would likely experience increased energy levels, anxiety, or insomnia.

Choice B rationale

Weight gain is a classic symptom of hypothyroidism, not thyrotoxicosis. When the body's metabolism slows down due to insufficient thyroid hormone, the client may gain weight. A client experiencing thyrotoxicosis from an excessive dose of levothyroxine would typically exhibit a hypermetabolic state, which often leads to unintended weight loss despite an increased appetite.

Choice C rationale

A fever is a sign of an accelerated metabolic rate, which is a key feature of thyrotoxicosis. When thyroid hormone levels become excessively high, the body's basal metabolic rate increases significantly, causing an increase in body temperature. This can manifest as a low-grade fever or even a significant fever in severe cases, requiring immediate medical attention.

Choice D rationale

Bradycardia, or a slow heart rate, is a symptom of hypothyroidism. The heart rate slows down as the body's overall metabolic processes decrease. Thyrotoxicosis is characterized by a rapid heart rate, known as tachycardia. This is due to the excessive stimulation of the cardiovascular system by high levels of thyroid hormone. A normal heart rate is typically between 60 and 100 beats per minute. .

A. Tomato soup. B. White fish. C. Hot cocoa. D. Decaffeinated coffee.

Correct Answer is B

Explanation

Choice A rationale

Tomato soup is highly acidic due to its tomato base, which can relax the lower esophageal sphincter (LES) and increase stomach acid production. This can lead to the reflux of gastric contents into the esophagus, exacerbating the symptoms of GERD. The client should avoid highly acidic foods to manage their condition effectively.

Choice B rationale

White fish is a lean protein that is generally low in fat. High-fat foods can delay stomach emptying and decrease the pressure of the lower esophageal sphincter, increasing the risk of acid reflux. Lean proteins like white fish are less likely to trigger symptoms and are therefore a suitable dietary choice for a client with GERD.

Choice C rationale

Hot cocoa contains both caffeine and fat, which are known to exacerbate GERD symptoms. Caffeine can relax the lower esophageal sphincter, allowing stomach acid to reflux. Additionally, the fat content can delay gastric emptying, increasing pressure on the LES and worsening acid reflux symptoms.

Choice D rationale

Decaffeinated coffee can still trigger GERD symptoms. Coffee, even without caffeine, is acidic and can stimulate the production of stomach acid. The oils and compounds in coffee can also relax the lower esophageal sphincter, increasing the likelihood of acid reflux and causing irritation to the esophageal lining.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has a new prescription for levothyroxine about thyrotoxicosis. The nurse should instruct the client to monitor and report which of the following findings?

Correct Answer is C

Explanation

A nurse is teaching a client who has GERD about appropriate dietary choices. Which of the following food choices by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is assessing a 2-year-old male toddler in a pediatric clinic during a well-child checkup. Exhibits After reviewing the toddler’s current medical record, which of the following interventions should the nurse expect the provider to prescribe?

A nurse is assessing a client who has schizophrenia prior to administering the client's next dose of clozapine. Which of the following findings should the nurse report to the provider?

A nurse is teaching a newly licensed nurse about advance directives. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A nurse is providing dietary teaching to the guardian of a preschooler who has celiac disease. Which of the following foods should the nurse recommend including in the preschooler's diet?

A nurse is documenting admission data for a client in an acute care facility. Which of the following actions should the nurse take.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

A nurse is planning care for a client who has a history of urinary tract infections (UTIs) and requires placement of an indwelling urinary catheter. Which of the following actions should the nurse take to help minimize the client's risk for acquiring a UTI?

A nurse is planning care for an older adult client who has dementia and a nutritional deficit. Which of the following actions should the nurse plan to take?