The client is brought to the ER after falling off a roof and landing on his back. A T4 spinal fracture is diagnosed. The client's blood pressure is 74/40 mmHg, pulse is 55/min, and skin is pink and dry. What of the following nursing actions is a priority?
Determine if blood is present in urine
Perform a neurological assessment
Administer IV normal saline
Perform a 12-lead electrocardiogram
The Correct Answer is C
Choice A rationale: Although important to assess for potential kidney injury, addressing hypotension due to potential spinal shock takes priority.
Choice B rationale: Important for determining any neurological deficits, but addressing hypotension is the initial priority.
Choice C rationale: Hypotension indicates potential spinal shock or hemorrhagic shock, and fluid resuscitation is the immediate priority to stabilize the client's blood pressure.
Choice D rationale: While important for assessing cardiac status, addressing hypotension takes precedence to stabilize the client's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: With type 2 diabetes, insulin secretion is decreased, and insulin resistance is increased. This means that the pancreas does not produce enough insulin, and the cells of the body do not respond well to the insulin that is available. Insulin is a hormone that helps the body use glucose (sugar) for energy. Without enough insulin or with insulin resistance, glucose builds up in the blood, leading to high blood sugar levels and various complications.
Choice B rationale: This statement describes Type 1 diabetes, where the immune system destroys insulin-producing cells.
Choice C rationale: This describes type 1 diabetes, not type 2 diabetes. People with type 2 diabetes may or may not need to take insulin, depending on how well they can control their blood sugar levels with diet, exercise, and oral medications.
Choice D rationale: This refers to pancreatitis, which is a condition where the pancreas becomes inflamed due to infection, injury, or alcohol abuse. Pancreatitis can cause
severe abdominal pain, nausea, vomiting, fever, and elevated levels of pancreatic enzymes in the blood.
Correct Answer is A
Explanation
Choice A rationale: This is the correct answer. It corresponds to 300 mg of the drug ((300x 5)/250).
Choice B rationale: This is incorrect because it is too low. It is the amount of milliliters that corresponds to 200 mg of amoxicillin trihydrate, which is less than the prescribed dose of 300 mg.
Choice C rationale: This is incorrect because it is too low. It is the amount of milliliters that corresponds to 60 mg of amoxicillin trihydrate, which is not enough to treat an oral infection.
Choice D rationale: This is incorrect because it is too low. It is the amount of milliliters that corresponds to 250 mg of amoxicillin trihydrate, which is less than the prescribed dose of 300 mg.
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