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 A
Explanation
This can help prevent dizziness and loss of balance, which are common symptoms of Ménière’s disease.
Choice B is not correct because range-of-motion exercises to the client’s neck every 4 hours are not a standard intervention for Ménière’s disease.
Choice C is not correct because aspirin is not always the recommended medication for headaches associated with Ménière’s disease.
Choice D is not correct because limiting fluid intake is not a standard intervention for Ménière’s disease.
Correct Answer is C
Explanation
Applying an ice pack can help reduce pain and swelling after total knee arthroplasty.
Placing pillows under the client’s knee (choice A) is not recommended as it can hinder circulation and delay healing.
Performing range-of-motion exercises to the client’s knee (choice B) may be part of the rehabilitation process but should be done under the guidance of a physical therapist and may not be appropriate for immediate pain relief.
Gently massaging the area around the client’s incision (choice D) may not be appropriate as it can cause discomfort and disrupt the healing process.
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