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Patient Data

Click to highlight the prescriptions that the nurse should perform first.

2000

Obtain lactic acid level

Admit to step-down intensive care unit (ICU)

Insert indwelling catheter for accurate intake and output (180) monitoring

Infuse 0.9% sodium chloride 30 mL/kg bolus now, then 150 mL/hour after bolus

Cefepime 1 gram every 8 hours intravenous piggyback (IVPB)

Acetaminophen 650 mg by mouth (PO) for pain or for temperature above 100.4 F (38 C)

1 to 5 L/minute of oxygen as needed to maintain saturations greater than 92% via nasal cannula

Obtain lactic acid level

Admit to step-down intensive care unit (ICU)

Insert indwelling catheter for accurate intake and output (180) monitoring

Infuse 0.9% sodium chloride 30 mL/kg bolus now, then 150 mL/hour after bolus

Cefepime 1 gram every 8 hours intravenous piggyback (IVPB)

Acetaminophen 650 mg by mouth (PO) for pain or for temperature above 100.4 F (38 C)

1 to 5 L/minute of oxygen as needed to maintain saturations greater than 92% via nasal cannula

Answer and Explanation

The Correct Answer is ["A","D","E"]

Rationale:

• Infuse 0.9% sodium chloride 30 mL/kg bolus now, then 150 mL/hour after bolus: The client is showing signs of systemic inflammatory response syndrome (SIRS) with hypotension, tachycardia, and elevated WBC count, suggesting early sepsis or sepsis risk. Administering a fluid bolus is a priority intervention to improve tissue perfusion, restore intravascular volume, and prevent progression to septic shock.

• Obtain lactic acid level: Lactic acid is a critical marker of tissue hypoperfusion and cellular oxygen deficit. Early measurement helps identify sepsis severity and guides treatment, including fluid resuscitation and vasopressor therapy if needed. Prompt assessment ensures timely recognition of worsening perfusion and organ dysfunction.

• Cefepime 1 gram every 8 hours intravenous piggyback (IVPB): Early empiric broad-spectrum antibiotics are essential in suspected sepsis or SIRS from infection. Cefepime targets a wide range of gram-negative and gram-positive organisms, which is important given the patient’s postoperative wound and elevated WBC count.

• Admit to step-down intensive care unit (ICU): While ICU-level monitoring may be needed eventually, the immediate priority is stabilizing the client’s perfusion and initiating early treatment for suspected sepsis. Admission alone does not provide urgent intervention to prevent deterioration.

• Insert indwelling catheter for accurate intake and output monitoring: Accurate I&O monitoring is important in managing fluid status, but it is not the first priority before hemodynamic stabilization, fluid resuscitation, and initiation of antibiotics.

• Acetaminophen 650 mg by mouth (PO) for pain or temperature above 100.4 °F (38 °C): Fever control and pain management are supportive measures. They do not address the life-threatening risk of sepsis or impaired perfusion and should be performed after fluid resuscitation and initiation of antibiotics.

• 1 to 5 L/minute of oxygen as needed to maintain saturations greater than 92% via nasal cannula: The client’s oxygen saturation is 94% on room air, which is adequate. Oxygen therapy may be used if saturation drops, but immediate perfusion and infection management take priority.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:
A. Assess the client's blood pressure: Progression to third-degree AV block can significantly impair cardiac output due to loss of atrioventricular synchrony. Assessing blood pressure helps determine hemodynamic stability and guides urgency of further interventions such as pacing.

B. Administer propranolol via IV push (IVP): Propranolol is a beta-blocker that further slows AV nodal conduction and can worsen complete heart block. Its administration may precipitate severe bradycardia, hypotension, or cardiac arrest. AV nodal–blocking agents are contraindicated in third-degree AV block.

C. Document the increase in the client's heart rate: Third-degree AV block is characterized by atrial and ventricular dissociation, often with a slow ventricular escape rhythm. An increase in heart rate is not expected and is not the priority focus. Immediate assessment of perfusion takes precedence over documentation.

D. Initiate cardiopulmonary resuscitation (CPR): CPR is indicated only if the client is pulseless or in cardiac arrest. Clients with third-degree AV block may still have a perfusing rhythm. Assessment and preparation for advanced interventions are required before initiating resuscitation measures.

Correct Answer is []

Explanation

Rationale:

• Acute kidney injury: The client demonstrates markedly reduced urine output (oliguria), significant weight gain due to edema, and a history of hypovolemic shock with vasopressor support, all of which increase the risk for acute kidney injury. AKI can result from ischemic injury to the kidneys during shock and fluid shifts.

• Measure electrolyte levels: Electrolyte monitoring is essential in AKI, as kidney impairment can cause imbalances in potassium, sodium, and other ions. Detecting changes early prevents complications such as cardiac arrhythmias and neurologic disturbances. Electrolyte trends also guide fluid management and medication dosing.

• Assess lung sounds: Fluid retention from oliguria can lead to pulmonary edema. Assessing lung sounds helps identify crackles, wheezing, or other indications of fluid overload. Early detection allows timely interventions such as adjusting fluid administration or initiating diuretic therapy.

• Daily weight: Daily weight measurement is a reliable indicator of fluid retention or loss. The client’s rapid weight gain reflects edema and fluid accumulation, which correlates with worsening kidney function. Tracking weight trends informs the effectiveness of interventions and fluid management.

• Hemoglobin: Hemoglobin monitoring is important because anemia can occur from hemodilution, blood loss, or renal impairment. Decreased hemoglobin can worsen oxygen delivery to tissues and complicate recovery. Regular assessment ensures timely interventions like transfusions if needed.

• Hypovolemia: The client is demonstrating fluid overload rather than depletion, as evidenced by edema and weight gain. Hypovolemia is characterized by low blood pressure, tachycardia, and reduced perfusion, which are not present here.

• Hemorrhage: There is no active bleeding; the surgical site is intact with no drainage. Hemorrhage would present with hypotension, tachycardia, and signs of blood loss, which are absent.

• Septic shock: The client is afebrile, hemodynamically stable on this day, and without signs of infection. Although sepsis can cause oliguria, the current presentation is more consistent with post-shock AKI rather than systemic infection.

• Hold pressure on the surgical site: The surgical site is intact with no active bleeding, so applying pressure is unnecessary and would not affect AKI.

• Give 1,000 mL of isotonic solution IV: Excessive fluid administration could worsen edema and fluid overload in AKI. Careful fluid balance is required rather than liberal IV fluid boluses.

• Alert the rapid response team: The client is stable on the current assessment; there are no acute deterioration signs necessitating immediate rapid response activation.

• Capillary refill: While capillary refill assesses perfusion, this client’s perfusion is adequate. It is not a sensitive indicator for ongoing AKI or fluid overload.

• Surgical site drainage: There is no active drainage or bleeding; monitoring the site is routine but not a primary parameter for AKI.

• Electrocardiogram: ECG monitoring may be indicated for electrolyte disturbances, but daily monitoring is not the first-line parameter unless arrhythmias are suspected. Daily lab and clinical monitoring are more direct indicators.

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Naxlex Comprehensive Predictor Exams

The client's 12-lead electrocardiogram (ECG) waveform indicates the rhythm has changed from 1st degree to 3rd degree atrioventricular (AV) heart block. Which intervention should the nurse implement?

Correct Answer is A

Explanation

Patient Data Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

After an endotracheal intubation is performed, bilateral breath sounds can be auscultated. No epigastric gurgling can be heard, and there is an audible gurgle from the client's mouth. Which intervention should the nurse implement?

A client is brought to the emergency department (ED) following a motor vehicle collision with blunt trauma to the chest. Which finding should the nurse report immediately to the healthcare provider (HCP)?

Patient Data During the central line placement, the healthcare provider (HCP) gives the nurse a sample of blood to send to the laboratory. Which 4 laboratory values would be most important to monitor this client's condition?

The healthcare provider (HCP) prescribes lidocaine 4 mg/minute IV for a client experiencing premature ventricular contractions (PVCS). The IV bag contains lidocaine 1 gram in 500 mL DW. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only)

The nurse is preparing to start an IV infusion of 1,000 mL of 0.9% sodium chloride with 30 mEq of potassium chloride for a client with diabetic ketoacidosis (DKA). Before implementing the prescription, which assessment finding is most important for the nurse to obtain?

The rapid response team transfers a client with sepsis to the intensive care unit (ICU). The client's white blood cell count is 28,000/mm3 (28 x 10^9/L). Which intervention should the nurse implement first? Reference Range: White blood cell (WBC) [5,000 to 10,000/mm3 (5 to 10 x 10^9/L)]

After seven days of mechanical ventilation, an older adult client is extubated and is now receiving 50% oxygen via face mask. The client has become anxious and is beginning to hyperventilate. Which intervention is most important for the nurse to implement?