Exhibit 1 Exhibit 2 Graphic Record Blood pressure 176/122 mm Hg Heart rate 136/min Respiratory rate 32/min Exhibit 3 O2 saturation 88%.

A nurse in the emergency department is caring for a client who was involved in an explosion.

Which of the following actions should the nurse plan to take first? (Click on the "Exhibit" button for additional information about the client.

Obtain an ECG.

Calculate the extent of burns using the rule of nines.

Notify the Rapid Response Team.

Initiate peripheral IV access.

Answer and Explanation

The Correct Answer is C

The nurse should plan to notify the Rapid Response Team first.
The client’s blood pressure is elevated, heart rate is high, respiratory rate is high, and oxygen saturation is low.
These are all signs of potential instability and the Rapid Response Team should be notified immediately.
Choice A is incorrect because while obtaining an ECG may be important, it is not the nurse’s first priority in this situation.
Choice B is incorrect because while calculating the extent of burns using the rule of nines may be important, it is not the nurse’s first priority in this situation.
Choice D is incorrect because while initiating peripheral IV access may be important, it is not the nurse’s first priority in this situation.

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Correct Answer is D

Explanation

A pacemaker sends electrical signals to the heart to regulate the heartbeat.
On an electrocardiogram (ECG), these signals appear as small spikes followed by a QRS complex, which represents the contraction of the ventricles.
Choice A, A regular sinus rhythm, is not the correct answer because a regular sinus rhythm is a normal heart rhythm that originates from the sinoatrial (SA) node and does not involve a pacemaker.
Choice B, A chaotic, irregular rhythm, is not the correct answer because a pacemaker is designed to regulate the heartbeat and prevent chaotic or irregular rhythms.
Choice C, the Absence of any electrical activity, is not the correct answer because a pacemaker sends electrical signals to the heart to regulate its activity.

A. Offer highly seasoned foods. B. Offer hot beverages with meals. C. Offer a snack prior to radiation therapy. D. Offer frequent, high-carbohydrate meals.

Correct Answer is D

Explanation

The nurse should plan to offer frequent, high-carbohydrate meals to the client who is receiving radiation and reports nausea since the therapy was initiated.
Eating smaller, more frequent meals rather than three large meals a day can help decrease nausea.
Choice A is incorrect because offering highly seasoned foods may not help with nausea.
Choice B is incorrect because offering hot beverages with meals may not help with nausea.
Choice C is incorrect because offering a snack prior to radiation therapy may not help with nausea.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client's heart rhythm following the insertion of a permanent pacemaker. Which of the following images should the nurse expect?

Correct Answer is D

Explanation

A nurse is caring for a client who is receiving radiation. The client reports nausea since the therapy was initiated. Which of the following considerations should the nurse include when planning the client's meals?

Correct Answer is D

Explanation

A nurse is preparing to administer 2 units of packed RBCs to a client. Which of the following actions should the nurse take?

A nurse is caring for a female client who has toxic shock syndrome. Which of the following findings should the nurse expect?

A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia. Which of the following assessment findings supports this suspicion?

A nurse is providing instructions about foot care for a client who has peripheral arterial disease. The nurse should identify which of the following statements by the client indicates an understanding of the teaching.

A nurse is preparing to administer naloxone 10 mcg/kg via IV bolus to a client who weighs 220 lb. The amount available is 0.4 mg/mL. How many mL should the nurse administer? (round off to the nearest tenth)

A nurse is administering furosemide 80 mg PO twice daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective?

A charge nurse receives a call from the house supervisor requesting room assignments for four new clients. Based on the admission diagnoses, which of the following clients requires a private room?

A nurse is caring for a client who has bladder cancer and a WBC count of 900/mm. Which of the following actions should the nurse take?