The nurse in the Emergency Department (ED) assesses a 17-year-old patient with blue-tinged lips, slowed respirations, and pinpoint pupils. The patient has no response to painful stimuli. Which of the following should be the nurse’s priority action?

Get the defibrillator to the patient’s bedside and open the crash cart.

Administer oxygen via 100% nonrebreather and place an IV catheter to give naloxone.

Administer naloxone intranasally if there is not an IV catheter in place.

Contact the patient’s parents or legal guardian for consent to treat.

Answer and Explanation

The Correct Answer is B

The correct answer is b. Administer oxygen via 100% nonrebreather and place an IV catheter to give naloxone.

Choice A Reason: Get the defibrillator to the patient’s bedside and open the crash cart

While having the defibrillator and crash cart ready is important in emergency situations, it is not the immediate priority in this scenario. The patient’s symptoms suggest opioid overdose, which requires immediate intervention to support breathing and reverse the effects of the opioid. The primary focus should be on ensuring adequate oxygenation and administering naloxone.

Choice B Reason: Administer oxygen via 100% nonrebreather and place an IV catheter to give naloxone

This is the correct answer. The patient’s blue-tinged lips, slowed respirations, and pinpoint pupils are indicative of opioid overdose. Administering oxygen via a 100% nonrebreather mask helps to ensure adequate oxygenation, while placing an IV catheter allows for the administration of naloxone, an opioid antagonist that can reverse the effects of the overdose. This intervention addresses the immediate life-threatening condition.

Choice C Reason: Administer naloxone intranasally if there is not an IV catheter in place

While administering naloxone intranasally is an appropriate alternative if IV access is not available, it is not the first priority. The initial focus should be on ensuring adequate oxygenation and establishing IV access for more effective administration of naloxone. If IV access cannot be quickly established, then intranasal naloxone can be used.

Choice D Reason: Contact the patient’s parents or legal guardian for consent to treat

Obtaining consent is important, but it is not the immediate priority in a life-threatening situation. The nurse’s primary responsibility is to stabilize the patient and address the acute medical emergency. Once the patient is stabilized, the nurse can then contact the parents or legal guardian for further consent and information.

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 ["B"]

Explanation

Choice A Reason: Family history

Family history is not a modifiable risk factor. It refers to the genetic predisposition to certain health conditions based on the medical history of one’s family. While it is important to be aware of family history to understand potential risks, it cannot be changed or modified through lifestyle adjustments.

Choice B Reason: Weight

Weight is a modifiable risk factor. Maintaining a healthy weight through diet and exercise can significantly reduce the risk of various health conditions, including heart disease, diabetes, and hypertension. Weight management is crucial for overall health and can be controlled through lifestyle changes.

Choice C Reason: Sedentary lifestyle

A sedentary lifestyle is a modifiable risk factor. Increasing physical activity and reducing sedentary behavior can improve cardiovascular health, enhance mental well-being, and reduce the risk of chronic diseases. Encouraging regular exercise and active living is essential for health improvement.

Choice D Reason: Alcohol consumption

Alcohol consumption is a modifiable risk factor. Limiting or avoiding alcohol can reduce the risk of liver disease, certain cancers, and other health issues. Moderation in alcohol intake is important for maintaining good health and preventing related complications.

A. Distinct wound borders to plantar aspect of foot B. +3 edema to the mid-calf C. Patient reports 9 (0-10) pain scale to area D. Irregular wound borders E. Minimal serous drainage

Correct Answer is ["B","D","E"]

Explanation

b. +3 edema to the mid-calf

d. Irregular wound borders

e. Minimal serous drainage

Explanation of Choices

Choice A Reason: Distinct Wound Borders to Plantar Aspect of Foot

Venous ulcers typically present with irregular wound borders rather than distinct ones. They are usually found on the lower legs, particularly around the medial malleolus (inner ankle), rather than the plantar aspect of the foot. The plantar aspect of the foot is more commonly associated with diabetic ulcers or pressure sores. Therefore, distinct wound borders to the plantar aspect of the foot are not indicative of a venous ulcer.

Choice B Reason: +3 Edema to the Mid-Calf

Edema, or swelling, is a common finding in patients with venous ulcers. Venous insufficiency leads to increased pressure in the veins, causing fluid to leak into the surrounding tissues, resulting in edema. The presence of +3 edema (a significant level of swelling) in the mid-calf is a strong indicator of venous insufficiency and, consequently, venous ulcers. This finding supports the diagnosis of a venous ulcer.

Choice C Reason: Patient Reports 9 (0-10) Pain Scale to Area

While pain can be associated with venous ulcers, it is not a definitive diagnostic criterion. Pain levels can vary widely among individuals with venous ulcers, and some may experience minimal discomfort. A pain scale rating of 9 out of 10 indicates severe pain, which could be due to various conditions, not specifically venous ulcers. Therefore, this finding alone is not sufficient to suspect a venous ulcer.

Choice D Reason: Irregular Wound Borders

Venous ulcers are characterized by their irregular wound borders. Unlike arterial ulcers, which have well-defined edges, venous ulcers tend to have uneven, irregular borders. This is due to the chronic nature of venous insufficiency and the ongoing damage to the skin and underlying tissues. The presence of irregular wound borders is a key indicator of a venous ulcer.

Choice E Reason: Minimal Serous Drainage

Venous ulcers often produce serous drainage, which is a clear to pale yellow fluid. The amount of drainage can vary, but minimal serous drainage is a common finding. This type of drainage is due to the chronic inflammation and fluid leakage associated with venous insufficiency. Therefore, minimal serous drainage is consistent with the presence of a venous ulcer.

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

The nurse in the Emergency Department (ED) assesses a 17-year-old patient with blue-tinged lips, slowed respirations, and pinpoint pupils. The patient has no response to painful stimuli. Which of the following should be the nurse’s priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client about ways to improve their health. Which of the following modifiable risk factors should the nurse include? (Select All that Apply)

Correct Answer is ["B"]

Explanation

Which of the following assessment findings would lead the nurse to suspect the client has a venous ulcer to the right lower extremity? (SELECT ALL THAT APPLY)

Correct Answer is ["B","D","E"]

Explanation

A nurse is providing care for a client who is malnourished and appears exhausted. What data would cause the nurse to suspect the client is a victim of human trafficking? The client:

The highest priority nursing action relative to the initial phase of alcohol withdrawal would be to:

The nurse is educating clients about recovery from alcohol abuse. Which statement by the client indicates that learning has occurred?

Psychiatric care technicians (PCTs) are unlicensed assistive personnel that are an integral part of the acute care mental healthcare team. Which of the following choices would be an example(s) of overdelegation by the nurse to a PCT? The nurse directs the PCT to (Select All that Apply):

A client presents to the Emergency Department (ED) after ingesting phencyclidine (PCP). Characteristic behaviors of an individual who has ingested PCP include:

The nurse assesses that medication teaching about tricyclic antidepressants was understood when the client states:

A client diagnosed with bipolar disorder is experiencing a severe depressive episode. Which client behavior would alert the nurse to the highest priority intervention? The client: