Exhibits

The nurse is reviewing the assessment findings.

Click to specify the client findings below that are of immediate concern to the nurse.

Body system

Nurses notes

Respiratory

Respiratory rate 14 breaths/minute

Oxygen saturation 82% on room air

Cardiovascular

Blood pressure 83/41 mm Hg

Heart rate 106 beats/minute

Respiratory rate 14 breaths/minute

Oxygen saturation 82% on room air

Blood pressure 83/41 mm Hg

Heart rate 106 beats/minute

Answer and Explanation

The Correct Answer is ["B","C"]

Finding:
•   Oxygen saturation 82% on room air
Reason for Concern:
•   Oxygen saturation of 82% is critically low, indicating severe hypoxemia. This requires immediate attention to ensure adequate oxygenation and prevent complications such as respiratory failure or cardiac arrest.
Body System: Cardiovascular
Finding:
•   Blood pressure 83/41 mm Hg
Reason for Concern:
•   Blood pressure is significantly low, indicating potential hypovolemic shock or severe hemorrhage. This needs to be addressed urgently to stabilize the client’s hemodynamic status and improve perfusion to vital organs.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Periodic sighing and shaking the head: These may be signs of frustration but are less urgent compared to more severe behaviors.
B. Argumentativeness and use of profanity: These behaviors indicate increased agitation and potential for escalation. Monitoring these behaviors is crucial to de-escalate the situation and ensure safety.
C. Decreased activity level and change in affect: While important to monitor for changes in mood, these are less immediately concerning compared to signs of escalating agitation.
D. Repeated requests for attention from the nurse: This behavior indicates a need for attention but is less concerning compared to potentially aggressive or escalating behaviors.

A. Dilute the dextrose in one liter of 0.9% normal saline solution. B. Ask the pharmacist to add the dextrose to a total parenteral nutrition (TPN) solution. C. Mix the dextrose in a 50 mL piggyback for a total volume of 100 mL. D. Push the undiluted dextrose slowly through the currently infusing IV. E. None F. None

Correct Answer is D

Explanation

A. Dilute the dextrose in one liter of 0.9% normal saline solution: Diluting 50% dextrose is not necessary for the treatment of insulin shock; it should be administered as ordered for rapid glucose delivery.
B. Ask the pharmacist to add the dextrose to a total parenteral nutrition (TPN) solution: This option is not appropriate for an acute insulin shock situation, which requires immediate administration of 50% dextrose.
C. Mix the dextrose in a 50 mL piggyback for a total volume of 100 mL: This is not necessary for the administration of 50% dextrose, which should be pushed as a concentrated solution.
D. Push the undiluted dextrose slowly through the currently infusing IV: This is the correct approach for administering a high-concentration dextrose solution to quickly address insulin shock.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client on the mental health unit has been scowling and rapidly pacing up and down the hall for several minutes. Which behaviors are most important for the nurse to monitor?

Correct Answer is B

Explanation

The nurse is preparing a 50 mL dose of 50% dextrose IV for a client with insulin shock. How should the nurse administer the medication?

Correct Answer is D

Explanation

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