The nurse is caring for a client admitted with moderate neck pain and numbness and tingling in the lower extremities after falling off a trampoline. The client is alert, oriented, with spontaneous movement of all extremities, respiratory rate of 16 breaths per minute and regular, heart rate of 96 beats per minute, and blood pressure of 124/76 mmHg. What action should the nurse take?

Apply supplemental oxygen via nasal cannula.

Administer intravenous morphine for pain.

Keep the hard collar in place until cleared.

Administer intravenous methylprednisolone (Solu-Medrol) as prescribed.

Answer and Explanation

The Correct Answer is C

Choice A reason: Supplemental oxygen is unnecessary with a normal respiratory rate (16) and stable vitals. Maintaining the collar prevents spinal injury, making this incorrect, as it’s not indicated compared to the nurse’s priority of ensuring spinal stability in a client with a fall history.

Choice B reason: Morphine for pain is premature without confirming spinal stability, as it may mask symptoms. Keeping the collar in place is critical, making this incorrect, as it risks missing neurological changes in the nurse’s care of a potential spinal injury client.

Choice C reason: Keeping the hard collar in place until cleared by imaging prevents worsening of potential spinal injury after a trampoline fall. This aligns with trauma care protocols, making it the correct action for the nurse to take to ensure the client’s safety and stability.

Choice D reason: Methylprednisolone is used for confirmed spinal cord injury, not suspected cases without imaging. Maintaining the collar is the priority, making this incorrect, as it’s premature compared to the nurse’s focus on spinal precautions in a client with numbness and tingling.

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Free Nursing Study Resources

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

Explanation

Choice A reason: A potassium level of 7.0 mEq/L risks lethal arrhythmias, necessitating cardiac monitoring. This aligns with hyperkalemia management, making it a correct priority action the nurse would plan to ensure the client’s safety and detect cardiac changes promptly.

Choice B reason: Notifying the provider is critical for a potassium level of 7.0 mEq/L, as urgent interventions like insulin or dialysis may be needed. This aligns with acute care protocols, making it a correct priority action for the nurse to address hyperkalemia.

Choice C reason: NPO status with ice chips is unrelated to hyperkalemia management, which focuses on lowering potassium. Cardiac monitoring is a priority, making this incorrect, as it’s not relevant to the nurse’s urgent actions for a client with severe hyperkalemia.

Choice D reason: Reviewing medications identifies potassium-containing or retaining drugs, preventing further elevation of 7.0 mEq/L. This aligns with hyperkalemia treatment, making it a correct priority action the nurse would plan to manage the client’s electrolyte imbalance effectively.

Choice E reason: Extra IV fluids (500 mL) may dilute potassium but risk fluid overload in acute kidney injury. Notifying the provider is more urgent, making this incorrect, as it’s not a priority compared to the nurse’s focus on immediate hyperkalemia interventions.

A. A client diagnosed with bipolar disorder receiving lithium carbonate (Lithobid). B. A client diagnosed with renal artery stenosis receiving losartan (Cozaar). C. A client diagnosed with lung cancer receiving vincristine (Oncovin). D. A client diagnosed with hyperthyroidism receiving methimazole (Tapazole).

Correct Answer is C

Explanation

Choice A reason: Lithium can cause nephrogenic diabetes insipidus, not SIADH, which involves excess ADH. Lung cancer is a known SIADH trigger, making this incorrect, as it’s unrelated to the syndrome compared to the high-risk client with cancer and vincristine therapy.

Choice B reason: Losartan treats hypertension in renal artery stenosis but doesn’t cause SIADH, which is linked to cancers. Lung cancer with vincristine is riskier, making this incorrect, as it’s not associated with the syndrome in the nurse’s risk assessment of clients.

Choice C reason: Lung cancer, especially small cell, and vincristine are strongly associated with SIADH due to ectopic ADH production. This aligns with oncology risk factors, making it the correct client most at risk for SIADH in the nurse’s outpatient clinic care.

Choice D reason: Hyperthyroidism and methimazole don’t typically cause SIADH, unlike lung cancer’s strong link. Vincristine-treated cancer is the highest risk, making this incorrect, as it’s not a primary cause of SIADH in the nurse’s evaluation of the outpatient clients.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with acute kidney injury has a serum potassium level of 7.0 mEq/L (7.0 mmol/L). The nurse would plan which actions as a priority? (Select all that apply)

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

Explanation

The nurse cares for clients in the outpatient clinic. Which client is MOST at risk for the syndrome of inappropriate antidiuretic hormone secretion (SIADH)?

Correct Answer is C

Explanation

Which situations are early signs of an ethical dilemma? (Select all that apply)

The nurse is reviewing a client’s record and notes that the primary health care provider has documented that the client has chronic kidney disease. On review of the laboratory results, the nurse most likely would expect to note which finding?

Which actions are considered best practices for the nurse to use during the administration of parenteral potassium to a client with a serum potassium level of 1.9 mEq/L (mmol/L)? (Select all that apply)

You are working on a busy unit and need to delegate tasks to the LPN and M

The nurse monitoring a client receiving peritoneal dialysis notes that the client’s outflow is less than the inflow. Which actions would the nurse take? (Select all that apply)

A client is actively bleeding from esophageal varices. Which medication would the nurse most expect to be administered to this client?