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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The priority topic for the nurse to review with the client is monitoring changes in weight.
A sudden weight gain may mean that the client’s heart failure is getting worse and they should call their doctor if they have a sudden weight gain, such as more than 2 to 3 pounds in a day or 5 pounds in a week.
Choice A is wrong because while daily exercise is important for overall health, it is not the priority topic for the nurse to review with the client.
Choice B is wrong because while daily sodium restrictions are important for managing heart failure, it is not the priority topic for the nurse to review with the client.
Choice C is wrong because while monitoring fluid intake is important for managing heart failure, it is not the priority topic for the nurse to review with the client.
Correct Answer is C
Explanation
The nurse should place the client in a position with their feet elevated.
This position helps to increase blood flow to the vital organs and can help improve the client’s blood pressure.
Choice A is not the answer because the Reverse Trendelenburg position does not help improve blood flow to vital organs.
Choice B is not the answer because the side-lying position does not help improve blood flow to vital organs.
Choice D is not the answer because High-Fowler’s position does not help improve blood flow to vital organs.
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