The client is a 51-year-old male with pneumonia.
The client has a history of hypertension and takes enalapril and a multivitamin daily.
His surgical history includes adenoid removal at age 4-years and a surgical repair of a fractured tibia at age 20. According to the client’s vital signs, he is experiencing which condition?

Hypothermia.

Tachypnea.

Hypotension.

Hypertension.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Hypothermia is a condition in which the body's core temperature falls below 95°F (35°C). It is not directly indicated by the client's vital signs as presented in the question.

Other factors that would more strongly suggest hypothermia include exposure to cold environments, immersion in cold water, or impaired thermoregulation due to conditions like hypothyroidism or alcohol intoxication.

Choice C rationale:

Hypotension is a condition in which blood pressure is abnormally low. It is also not directly indicated by the client's vital signs as presented in the question.

Hypertension, on the other hand, is a condition in which blood pressure is abnormally high.

The client's history of hypertension, and the fact that he takes enalapril (an antihypertensive medication), suggests that he may be more likely to experience hypertension than hypotension.

Choice D rationale:

Hypertension, as mentioned above, is a condition in which blood pressure is abnormally high.

While it's possible that the client is experiencing hypertension, the question specifically asks about the condition indicated by the client's vital signs.

Tachypnea, or rapid breathing, is a more direct indication of the client's respiratory distress, which is a common symptom of pneumonia.

Choice B rationale:

Tachypnea is the most likely condition indicated by the client's vital signs.

Tachypnea is often a sign of respiratory distress, which can be caused by a variety of conditions, including pneumonia. When a person has pneumonia, their lungs become inflamed and filled with fluid, making it difficult to breathe.

This can lead to rapid, shallow breathing, which is called tachypnea.

Other signs of respiratory distress that may be present in a client with pneumonia include: Coughing

Wheezing Chest pain

Feeling short of breath

Use of accessory muscles to breathe (e.g., muscles in the neck and chest) Nasal flaring

Cyanosis (a bluish tint to the skin)

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Correct Answer is C

Explanation

Choice A rationale:

A regular rapid heartbeat (tachycardia) is a common side effect of albuterol, a bronchodilator that relaxes the muscles in the airways to improve breathing. It's often expected after repeated doses. While it warrants monitoring, it doesn't necessarily require immediate intervention unless it becomes significantly elevated or causes other symptoms.

Choice B rationale:

Increased anxiety can also accompany breathing difficulties and albuterol administration. It's crucial to address anxiety, but it's not the most urgent finding in this scenario. Calming techniques and reassurance can often help manage anxiety, while more severe cases might require additional interventions.

Choice C rationale:

Uncontrollable shaking (tremors) is a more serious side effect of albuterol, indicating excessive stimulation of the sympathetic nervous system. It can progress to serious complications like seizures or cardiac events. Immediate intervention is crucial to prevent these risks. Actions might include:

Holding the next albuterol dose Notifying the healthcare provider Monitoring vital signs closely

Administering medications to counteract the tremors, such as beta-blockers, if ordered

Choice D rationale:

Throat irritation is a possible side effect of albuterol, but it's generally mild and self-limiting. It doesn't typically warrant immediate intervention in the absence of other concerning symptoms.

A. Until a smaller angle can be restored. B. For long-term control of pain and swelling. C. Until the excess pressure is reduced. D. For long-term control of normal eye pressure.

Correct Answer is D

Explanation

Choice A rationale:

Incorrect. Open-angle glaucoma is not characterized by an abnormally small angle.

The angle in open-angle glaucoma is open, but the drainage system is not working properly. Therefore, restoring a smaller angle would not be an effective treatment goal.

Choice B rationale:

Incorrect. Eye drops used to treat open-angle glaucoma are not typically used for pain control.

While some individuals may experience mild discomfort associated with elevated eye pressure, pain is not a common symptom of open-angle glaucoma.

Additionally, eye drops used to treat glaucoma do not have anti-inflammatory properties to address swelling.

Choice C rationale:

Incorrect. While reducing excess eye pressure is an important initial goal of treatment, long-term management of open-angle glaucoma requires ongoing maintenance of normal eye pressure.

Simply reducing pressure temporarily is not sufficient to prevent vision loss.

Choice D rationale:

Correct. The primary goal of treatment for open-angle glaucoma is to maintain normal eye pressure over the long term. This is because elevated eye pressure can damage the optic nerve, leading to vision loss.

Eye drops are often used to lower eye pressure, and they typically need to be used for life to prevent vision loss.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with emphysema reports difficulty breathing and exhibits audible wheezing.The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants immediate intervention by the nurse?

Correct Answer is C

Explanation

A client with open-angle glaucoma asks the nurse how long the prescribed eye drops will need to be used. Which response made by the nurse is accurate?

Correct Answer is D

Explanation

The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results.Which diagnostic test should the nurse review to confirm the diagnosis of TB?

The healthcare provider prescribes an IV solution of clindamycin 850 mg in 75 ml of D5W to infuse over 30 minutes. The drop factor is 15 gtt/mL. The nurse should regulate the IV to deliver how many gtt/minute? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

The nurse is caring for a client who is taking diclofenac for rheumatoid arthritis. During a clinic visit, the client appears pale and reports increasing fatigue. Which of the client’s serum laboratory values is most important for the nurse to review?

A client is recovering from the surgical removal of glass in the right eye.Which intervention should the nurse implement immediately following the procedure?

The nurse is caring for a client with emphysema who is mildly dyspneic after ambulation. Which instruction should the nurse provide to the client to improve gas exchange?

A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?

The healthcare provider prescribes bismuth subsalicylate, metronidazole, tetracycline, and pantoprazole for a client with a Helicobacter pylori (H. pylori) infection.Prior to administering theH. pylori treatment regimen, the nurse should review the electronic medical record for which medication?