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
White rice is a low-potassium food that can be recommended for a client who has chronic kidney disease and must limit potassium intake.
Nonfat yogurt (choice A) contains moderate amounts of potassium and may not be the best choice for someone who needs to limit their potassium intake.
A medium baked potato with skin (choice B) is high in potassium and should be limited to a low-potassium diet.
Peanut butter (choice C) also contains moderate amounts of potassium and may not be the best choice for someone who needs to limit their potassium intake.
Correct Answer is A
Explanation
Place two-bed pillows between the legs when in bed.
To prevent hip dislocation after total hip arthroplasty, the nurse should place two-bed pillows between the client’s legs when in bed.
This helps maintain proper alignment and prevent the hip from dislocating.
Choice B is incorrect because leaning forward when attempting to stand can increase the risk of hip dislocation.
Choice C is incorrect because removing the wedge device when turning can increase the risk of hip dislocation.
Choice D is incorrect because elevating the knees higher than the hips when sitting can increase the risk of hip dislocation.
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