Complete the following sentence by using the list of options.
The nurse should first anticipate the need to
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Rationale:
• Obtain IV access is the first priority because the client is showing signs of hypovolemic shock low blood pressure (76/45 mm Hg), tachycardia (HR 121/min), pale mucous membranes, and diaphoresis likely due to GI bleeding. Immediate vascular access is necessary for resuscitation and fluid administration.
• Call the surgical suite to notify that the client is arriving STAT would delay essential stabilization. Transporting an unstable client without securing IV access and fluid resuscitation could worsen their condition and is unsafe.
• Place the client in a supine position with feet elevated (modified Trendelenburg) might temporarily improve venous return, but it does not address the underlying fluid deficit. It is not a substitute for urgent fluid replacement via IV access.
• Recheck the client's oxygen saturation is not a priority because the client already has a stable oxygen saturation of 98% on room air. The immediate threat is circulatory collapse, not hypoxia.
• Prepare to administer IV fluids follows IV access to treat hypotension and restore circulating volume. IV fluids help stabilize hemodynamics while awaiting further interventions like endoscopy or blood transfusion if needed.
• Transport the client for endoscopy is inappropriate at this moment because the client is hemodynamically unstable. Endoscopy is important but must be delayed until the client is stabilized.
• Check the ECG may be useful if cardiac concerns arise due to hypotension or tachycardia, but it does not take precedence over immediate circulatory support in this scenario.
• Check arterial blood gases would not provide data that immediately changes the management. The client's O2 saturation is normal, and ABGs are not needed to diagnose or treat hypovolemic shock due to GI bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Dilated pupils: Hydromorphone, an opioid, typically causes pupil constriction (miosis), not dilation. Dilated pupils may occur in opioid overdose only as a sign of severe hypoxia, but are not a common adverse effect of appropriate therapeutic dosing.
B. Urinary retention: Urinary retention is a known adverse effect of opioids like hydromorphone. Opioids can impair bladder muscle tone and suppress the urge to void by affecting central and peripheral nervous system pathways.
C. Hypertension: Hydromorphone generally causes hypotension due to vasodilation and histamine release. Hypertension is not a typical response and would more likely suggest untreated pain or another underlying condition.
D. Tachypnea: Opioids depress the respiratory center in the brain, which can lead to bradypnea rather than tachypnea. An increase in respiratory rate is not characteristic of opioid use unless it’s a response to severe, unmanaged pain.
Correct Answer is ["A","D","E","F"]
Explanation
Rationale:
• 3-month history of unplanned weight loss, increased sweating, heat intolerance, fatigue, and insomnia: These symptoms are consistent with hypermetabolic activity seen in hyperthyroidism, particularly Graves’ disease, and require follow-up and management to prevent complications like thyroid storm.
• Last menstrual period was 3 months ago: Amenorrhea can occur due to hormonal imbalance caused by elevated thyroid hormones. This finding indicates endocrine dysfunction and should be investigated further.
• Skin is warm and moist. Exophthalmos noted, goiter visualized on neck: These are classic physical signs of Graves’ disease, an autoimmune hyperthyroid condition. The exophthalmos (protruding eyes) and goiter (thyroid enlargement) are abnormal and require follow-up.
• Client's partner reports that the client is irritable and anxious lately: Mood changes, such as irritability and anxiety, are common in hyperthyroidism and may affect the client’s quality of life and safety. This finding warrants further psychological and endocrine evaluation.
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