Exhibits
Highlight the 3 orders that should be completed first.
Orders
- Administer oxygen 5 L/minute via simple face mask
- Vital signs ever 1 hour
- X-ray of the right arm and cervical spin
- Place 2 large bore peripheral IV's
- Computed tomography scan of the brain
- Give 1 Liter bolus of 0.9% sodium chloride solution IV once
- Bacitracin applied topically to lacerations every 12 hours
Administer oxygen 5 L/minute via simple face mask
Bacitracin applied topically to lacerations every 12 hours
Place 2 large bore peripheral IV's
X-ray of the right arm and cervical spin
Computed tomography scan of the brain
Vital signs ever 1 hour
Give 1 Liter bolus of 0.9% sodium chloride solution IV once
The Correct Answer is ["A","C","G"]
A. Administer oxygen 5 L/minute via simple face mask: Oxygen administration is a priority intervention to improve oxygenation and address the client's low oxygen saturation of 82%.
Hypoxemia can lead to tissue hypoxia and further compromise the client's condition. Therefore, administering oxygen should be the first action taken to ensure an adequate oxygen supply to vital organs.
B. Bacitracin applied topically to lacerations every 12 hours: While wound care is important, administering oxygen and establishing IV access take precedence over topical
treatment. Oxygenation and fluid resuscitation are critical in the immediate management of a trauma patient to ensure adequate tissue perfusion and oxygen delivery.
C. Place 2 large bore peripheral IV's: Establishing IV access is essential for administering medications and fluids rapidly. This is particularly important in this scenario where the client may require immediate fluid resuscitation due to hypotension (blood pressure of 83/41 mm Hg).
Large bore IV access allows for rapid infusion of fluids and medications to stabilize the client's hemodynamic status.
D. X-ray of the right arm and cervical spine: While diagnostic imaging is important for assessing injuries, it is not as urgent as administering oxygen and establishing IV access. Oxygenation and fluid resuscitation are higher priorities to stabilize the client's condition before proceeding with diagnostic tests.
E. Computed tomography scan of the brain: While a CT scan of the brain is essential for assessing potential head injuries, the immediate focus should be on stabilizing the client's oxygenation and hemodynamic status. Administering oxygen and fluids take precedence over diagnostic imaging to address the client's hypoxemia and hypotension.
F. Vital signs every 1 hour: Monitoring vital signs is important for ongoing assessment, but it is not as urgent as administering oxygen and fluids. Vital signs should be monitored closely, but immediate interventions to address hypoxemia and hypovolemia are critical to stabilize the client's condition.
G. Give 1 Liter bolus of 0.9% sodium chloride solution IV once: The client's hypotension (blood pressure of 83/41 mm Hg) indicates hypovolemia and the need for fluid resuscitation. Administering a bolus of intravenous fluids (1 Liter bolus of 0.9% sodium chloride solution) is essential to address hypovolemia and improve perfusion to vital organs. This intervention helps stabilize the client's blood pressure and prevent further deterioration of her condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Hypocalcemia:
- Condition: Hypocalcemia is a condition characterized by low levels of calcium in the blood. In newborns and infants, this can occur due to inadequate intake or absorption of calcium, and it can manifest as seizures.
- Rationale: The infant was fed cow's milk, which is not recommended for infants under one year old and can interfere with calcium absorption, possibly leading to hypocalcemia. Seizures can be a symptom of severe hypocalcemia.
Actions to Take:
1. Administer oral calcium:
- Rationale: Direct administration of calcium helps to quickly elevate calcium levels in the blood, addressing the immediate cause of the seizures.
2. Educate the mother on nutrition needs:
- Rationale: It's important to educate the mother on the appropriate nutritional needs for an
infant, emphasizing the importance of breastfeeding or formula feeding instead of cow's milk, to prevent recurrence.
Parameters to Monitor:
1. Electrocardiogram:
- Rationale: Monitoring the ECG is crucial as hypocalcemia can cause cardiac arrhythmias, and the ECG can provide real-time information about the infant's cardiac status.
2. Oxygen saturation:
- Rationale: Monitoring oxygen saturation ensures that the infant maintains adequate oxygenation, especially after a seizure and during recovery, to detect any respiratory complications early.
Correct Answer is A
Explanation
A. Administer oxygen via face mask. The decrease in fetal heart rate after contractions indicates possible fetal distress. Administering oxygen to the mother can increase oxygen delivery to the fetus, potentially improving fetal oxygenation and alleviating distress.
B. Apply an Internal fetal heart monitor. While continuous monitoring is important, the first priority is to address the immediate fetal distress. Monitoring alone will not address the issue.
C. Notify the healthcare provider. Notifying the provider is important, but addressing the immediate fetal distress takes priority.
D. Use a vibroacoustic stimulator. Vibroacoustic stimulation can be used to assess fetal well- being, but it does not address the underlying fetal distress, which is the priority.
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