A nurse is caring for a client in the emergency department. Which action should the nurse take based on the client’s medication administration record at 1130?
Administer Albuterol nebulizer 2.5 mg stat.
Administer Methylprednisolone 50 mg IV stat.
Reassess the client’s vital signs before administering medications.
Notify the provider if the client has worsening symptoms after administration.
The Correct Answer is C
Choice A rationale
Administering Albuterol nebulizer 2.5 mg stat is appropriate for acute bronchospasm. Albuterol is a beta-agonist that relaxes airway smooth muscles, improving oxygenation. It is only administered when clinically indicated.
Choice B rationale
Methylprednisolone 50 mg IV is used for severe inflammation. It suppresses immune responses and reduces cytokine activity, but it does not directly address acute symptoms needing immediate intervention.
Choice C rationale
Reassessing vital signs ensures the patient’s stability before administering medications. This is vital in emergencies to evaluate therapy needs and prevent further clinical deterioration.
Choice D rationale
Notifying the provider about worsening symptoms after administration ensures timely interventions. However, preemptive measures, like reassessing stability, take priority before escalation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The presence of white blood cells in urine (pyuria) suggests infection rather than occlusion. White blood cells are part of the immune response and indicate inflammation or urinary tract infection.
Choice B rationale
Cloudy urine results from debris, bacteria, or excess proteins, often associated with infection rather than occlusion. While significant, cloudy urine does not directly signify mechanical blockage of the catheter.
Choice C rationale
Urinary urgency is more commonly a symptom of bladder irritation or infection and not catheter occlusion. Catheterization bypasses the bladder, reducing the likelihood of perceived urgency.
Choice D rationale
Bladder distention occurs when urine accumulates due to impaired drainage, a classic sign of catheter occlusion. It indicates a mechanical blockage, preventing normal urinary flow through the catheter.
Correct Answer is C
Explanation
Choice A rationale
Washing hands with cold water is less effective for removing pathogens compared to warm water. Warm water opens pores and enhances soap’s efficacy in breaking down oils and debris. Duration is also insufficient.
Choice B rationale
Washing for 10 seconds does not provide sufficient time for thorough microbial removal as evidence supports 15-20 seconds for optimal hand hygiene. Air drying increases the risk of recontamination and bacterial persistence.
Choice C rationale
Using soap and warm water for at least 15 seconds effectively removes microorganisms, reducing cross-infection. Drying with clean paper towels prevents bacterial growth and contamination compared to air drying or reused cloths.
Choice D rationale
Washing with water alone lacks the surfactant action of soap, which emulsifies oils and debris carrying bacteria. Drying with a clean towel prevents contamination but cannot compensate for soap absence.
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