The client is awake and alert, interacting with parents at the bedside.
She has thin, copious mucus from her nose and mouth and a cough.
She took her bottle in 20 minutes, with no issues.
The client’s monitor alarmed, oxygen saturation is 59%. She is cyanotic.
The client was placed in a knee-to-chest position, and the rapid response team was called.
What could be the potential cause of the client’s condition?

Seizure activity.

Arrhythmia.

Increased oxygen demand.

Acidosis.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Seizure activity typically presents with symptoms such as convulsions, loss of consciousness, or abnormal behavior, which are not described in the scenario.
Choice B rationale
Arrhythmia, or an abnormal heart rhythm, could potentially cause a sudden drop in oxygen saturation and cyanosis. It could also lead to a rapid response team being called.
Choice C rationale
Increased oxygen demand could potentially lead to low oxygen saturation. However, it would not typically cause cyanosis or require the rapid response team to be called unless it was associated with another condition such as heart or lung disease.
Choice D rationale
Acidosis, or a high level of acid in the body, could potentially cause low oxygen saturation. However, it would not typically cause cyanosis or require the rapid response team to be called unless it was severe or associated with another condition.

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Correct Answer is B

Explanation

Choice A rationale
While it’s important to evaluate the parent’s ability to care for the child, this does not directly address the parent’s fear of needles. The parent’s fear of needles is a specific issue that needs to be addressed in order to ensure the child receives the necessary insulin injections.
Choice B rationale
Determining if the child can administer the insulin is a potential solution to the parent’s fear of needles. Some children as young as 10 years old may be able to administer their own insulin injections with proper training and supervision. This would allow the child to manage their diabetes independently and alleviate the parent’s fear of needles.
Choice C rationale
Encouraging the parent to handle the needles may not be effective if the parent has a significant fear of needles. It’s important to respect the parent’s fear and find alternative solutions, such as having the child administer the insulin or finding another person who can assist with the injections.
Choice D rationale
Inquiring if there is another person who can assist with the injections is a potential solution to the parent’s fear of needles. If there is another person available who is comfortable administering the insulin injections, this could alleviate the parent’s fear and ensure the child receives the necessary care.

A. Acetaminophen B. Morphine C. Aspirin D. Albuterol

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

Explanation

Choice A rationale
Acetaminophen is a common medication that can be administered for pain relief and fever reduction. It is often used in a variety of clinical settings, including after the placement of an IV line.
Choice B rationale
Morphine is a strong opioid medication used to treat severe pain. It may be ordered after the placement of an IV line, especially if the patient is experiencing significant discomfort.
Choice C rationale
Aspirin is a medication that can be used for pain relief, fever reduction, and as an antiinflammatory. It may be ordered in a variety of clinical scenarios, including after the placement of an IV line.
Choice D rationale
Albuterol is a bronchodilator used to treat or prevent bronchospasm in people with reversible obstructive airway disease. It is not typically administered following the placement of a 5% dextrose intravenous line unless the patient has a pre-existing respiratory condition.
Choice E rationale
Racemic epinephrine is used to treat croup and asthma attacks. It is not typically administered following the placement of a 5% dextrose intravenous line unless the patient has a pre-existing respiratory condition.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse is reviewing the patient’s condition and vital signs following the placement of a 5% dextrose intravenous line. Which medications should the nurse anticipate the healthcare provider will order? Select all that apply.

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

Explanation

The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4° F (38° C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?

The nurse is providing treatment education to the caregiver of a school-age child recently diagnosed with ADHD. Which statement(s) made by the caregiver demonstrates an understanding?

An adolescent client who has successfully managed hemophilia for the past 10 years is evaluated by the nurse. Which behavior best evidences the client’s adjustment to the disorder as an adolescent?

The nurse is instructing the parent of a 10-year-old child newly diagnosed with type 1 diabetes mellitus (DM) on how to administer subcutaneous insulin injections. The parent expresses a fear of needles and is unable to perform the procedure. What intervention should the nurse implement?

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