After the nurse receives report, which client should the nurse assess first?
Client who is experiencing hallucinations and extreme anxiety after the use of marijuana.
Client with a history of alcohol use complaining of insomnia and diaphoresis.
Client who has a respiration rate of 14 after overdosing on oxycodone (OxyContin)
Client admitted with cocaine use who has an irregular heart rate of 142 beats / minute and a BP 186 /92 mmHg.
The Correct Answer is D
A. Client who is experiencing hallucinations and extreme anxiety after the use of marijuana: Hallucinations and anxiety are distressing but generally not life-threatening effects of marijuana use. These symptoms can be managed with reassurance and a calm environment once physical safety is ensured.
B. Client with a history of alcohol use complaining of insomnia and diaphoresis: These symptoms suggest early alcohol withdrawal, which can progress to serious complications like seizures or delirium tremens if untreated. However, at this stage, the client's symptoms are mild and not immediately life-threatening.
C. Client who has a respiration rate of 14 after overdosing on oxycodone (OxyContin): Although opioid overdose can cause respiratory depression, a rate of 14 indicates adequate ventilation for now. The client should still be closely monitored, but there is no immediate evidence of respiratory failure.
D. Client admitted with cocaine use who has an irregular heart rate of 142 beats/minute and a BP 186/92 mmHg: Cocaine toxicity can trigger severe cardiovascular complications. The markedly elevated heart rate and BP indicate acute sympathetic overactivity, which requires rapid stabilization and cardiac monitoring to prevent life-threatening outcomes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["900"]
Explanation
Calculation:
- Identify the infused volume and the total output volume.
Total measured output (drainage bag) = 2500 mL
Total infused irrigation solution = 1600 mL
- Calculate the actual urinary output (Actual Output = Total Output - Irrigation Infused).
Urinary Output (mL) = 2500 mL - 1600 mL
= 900 mL
Correct Answer is D
Explanation
Calculation:
- Determine the Total Dose Ordered per Minute
Ordered Rate: 12 mcg/kg/min
Client Weight: 75 kg
Total Dose (mcg/min) = 12 mcg/kg/min x 75 kg
= 900 mcg/min
- Convert to mg/min (1 mg = 1,000 mcg):
Total Dose (mg/min) = 900 mcg / 1,000
= 0.9 mg/min
- Determine the Concentration of the IV Solution
Available Drug: 1 g
Available Volume: 250 mL
- Convert Available Drug to mg (1 g = 1,000 mg):
Available Drug (mg) = 1 g x 1,000
= 1,000 mg
- Calculate Concentration (mg/mL):
Concentration (mg/mL) = 1,000 mg / 250 mL
= 4 mg/mL
- Calculate the Flow Rate in mL/hr
Flow Rate (mL/hr) = (Dose Ordered (mg/min) / Concentration (mg/mL)) x 60 min/hr
= (0.9 mg/min / 4 mg/mL) x 60 min/hr
= 0.225 x 60
= 13.5 mL/hr
- Round to the Nearest Whole Number
= 14.
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