The nurse enters her client’s room and finds the client complaining pf dyspnea, chest pain and syncope. The nurse assesses the client and notes the following findings. The client is pale and diaphoretic with a blood pressure of 90/60mmHg and respirations of 33. The client is anxious and fearing death. Which action should the nurse take first?

Administer oxygen via nasal cannula

Administer prescribed pain medications

Administer NS IV fluid

Ask the provider for a dopamine prescription

Answer and Explanation

The Correct Answer is A

A. Administer oxygen via nasal cannula: The client's symptoms of dyspnea, chest pain, syncope, and hypotension suggest a possible acute cardiovascular event, such as a myocardial infarction (MI) or pulmonary embolism (PE). Administering oxygen should be the priority to improve oxygenation and prevent hypoxia, which could exacerbate the client's symptoms and further compromise cardiac function.

B. Administer prescribed pain medications. Pain relief may be necessary, but stabilizing oxygen levels is the priority.

C. Administer NS IV fluid. Fluid administration may be helpful, but oxygenation is more critical in this situation to address the potential underlying respiratory or cardiac issue.

D. Ask the provider for a dopamine prescription. While dopamine may be used in cases of shock, the immediate action should be to ensure the client is adequately oxygenated.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Intracranial pressure (ICP) is now 15: Mannitol is an osmotic diuretic used to reduce intracranial pressure (ICP). The intended effect of the medication is to lower ICP. A decrease in ICP to 15 mmHg is within the normal range and indicates the medication has worked effectively.

B. The patient voids 250 mL over 2 hours is incorrect. While mannitol promotes diuresis, the amount of urine output alone does not directly indicate a reduction in ICP. The goal is to lower ICP, which is best assessed by measuring the ICP itself.

C. The patient's pupils are dilated and sluggish is incorrect. Dilated and sluggish pupils can be a sign of increased ICP, not a response to effective treatment.

D. Seizure behavior is absent is incorrect. While mannitol can help reduce ICP and potentially prevent seizures, the absence of seizure behavior is not a direct indicator of the medication's effect on ICP.

A. Deficits in the right visual field B. Motor retardation C. Poor impulse control D. Unable to discriminate words and letters

Correct Answer is C

Explanation

A. Deficits in the right visual field: This would be associated with a left-sided stroke, as the right hemisphere controls the left visual field.

B. Motor retardation: This is not a specific sign of right hemisphere stroke. It might be seen with other types of strokes.

C. Poor impulse control: A right hemisphere stroke may cause behavioral changes, including impulsivity, poor judgment, and difficulty in regulating emotions.

D. Unable to discriminate words and letters: This would suggest aphasia, which is typically associated with left hemisphere damage, as the left hemisphere controls language.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The health care provider prescribes IV mannitol for a client with an intracranial pressure (ICP) of 22. How will the nurse determine that the medication had the intended effect?

Correct Answer is A

Explanation

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor the client for which finding?

Correct Answer is C

Explanation

The client is found in ventricular fibrillation. What interventions should the team implement? Select All That Apply

The nurse is caring for a client who reports persistent, crushing chest pain. What additional signs or symptoms would make a nurse suspect that the client is experiencing a myocardial infarction?

The nurse is teaching a group of staff nurses about cardiac rhythms. The nurse would indicate that a U wave may indicate which of the following?

The nurse is caring for a client who is newly admitted with severe chest pain and suspected myocardial infarction. Which diagnostic blood test would be considered the most reliable and critical indicator of myocardial injury?

The nurse is caring for a client who is postoperative following a right below-the-knee amputation. The client asks the nurse, " I keep having pain in my right foot. Why is that?" Which response would be appropriate for the nurse to make?

The nurse is assessing a client with Paget's disease. Which finding would the nurse identify as being characteristic of this disease?

The nurse is caring for a client with advanced coronary artery disease who has developed cardiac arrest. During the resuscitation, the health care provider prescribes atropine. Which is the intended outcome of this medication?

The nurse is caring for a client who is found in cardiac arrest. Which medications would the nurse want to have available for their vasopressor effect? Select All That Apply