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.

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Correct Answer is D

Explanation

A. Elevated serum calcium levels: This is not typical for Paget's disease. While hypercalcemia can occur in advanced stages, the primary issue in Paget's disease is abnormal bone remodeling.

B. Elongated trunk: This is not characteristic of Paget's disease. Paget's disease affects bone remodeling and can lead to deformities such as bowing of the legs or enlarged bones, but not an elongated trunk.

C. Warm, swollen areas over femur: This can occur in Paget's disease due to increased blood flow to the affected bones, but it is not the most distinctive feature.

D. Mosaic pattern of bone: This pattern, which appears on X-ray, is a hallmark of Paget’s disease, indicating disorganized bone remodeling and a disruption of normal bone architecture.

A. BP 170/64 pulse 58 B. BP 180/90, pulse 96 C. BP 110/70, pulse 100 D. BP 100/60, pulse 54

Correct Answer is A

Explanation

A. BP 170/64, pulse 58: Cushing's triad includes increased systolic blood pressure with widened pulse pressure, bradycardia, and irregular respirations, indicating increased intracranial pressure.

B. BP 180/90, pulse 96: Hypertension is present, but the elevated pulse does not align with bradycardia seen in Cushing's triad.

C. BP 110/70, pulse 100: These values do not reflect the classic signs of Cushing's triad.

D. BP 100/60, pulse 54: While bradycardia is present, hypotension does not align with Cushing’s triad.

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is D

Explanation

A client has been admitted with a head injury from a motor vehicle accident. Vital signs on admission were BP 120/80 mm Hg and pulse 88. Which vital signs would indicate that Cushing's triad was occurring?

Correct Answer is A

Explanation

The nurse is caring for a client who has just had a pacemaker inserted. Which action should the nurse include in the initial plan of care?

The nurse is assessing a client who is near death. Which of the following findings would indicate to the nurse that the client is in the actively dying phase?

The nurse is preparing a client for an electrophysiology procedure. What statements would the nurse include when explaining this procedure to a client? Select All That Apply

The nurse obtains a health history from a patient with a prosthetic mitral value. Which question by the nurse would help to identify a risk factor for infectious endocarditis

A nurse is caring for client with increased intracranial pressure What is an appropriate nursing intervention for the client?

The nurse is caring for a client who is terminally ill and is being transferred to hospice at home. What would the nurse identify as the primary factor in planning the client's care in the home?