The nurse is caring for a client diagnosed with deep vein thrombosis who suddenly becomes short of breath, anxious, and restless.

The vital signs are: heart rate 130 beats/minute, respirations 42/minute, blood pressure 90/50, and pulse oximetry is 90%. An intravenous infusion of normal saline is running at 75ml/hr. The nurse elevates the head of the bed and applies nasal oxygen at 2L/min.

What action should the nurse take next?

Administer the PRN antianxiety medication.

Call the rapid response team.

Increase the intravenous infusion rate.

Prepare for mechanical ventilation.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Administering the PRN antianxiety medication is not the most appropriate next step. The client’s symptoms—shortness of breath, anxiety, restlessness, tachycardia, tachypnea, hypotension, and decreased oxygen saturation—are indicative of a potential pulmonary embolism, a life-threatening complication of deep vein thrombosis. While anxiety can be a symptom of a pulmonary embolism, treating it without addressing the underlying cause could delay necessary medical intervention.

Choice B rationale

Calling the rapid response team is the most appropriate next step. The client’s symptoms suggest a potential pulmonary embolism, a serious and life-threatening condition that requires immediate medical intervention. The rapid response team can provide the necessary urgent care.

Choice C rationale

Increasing the intravenous infusion rate is not the most appropriate next step. While hydration is important, it would not address the immediate life-threatening situation. The client’s symptoms suggest a potential pulmonary embolism, which requires immediate medical intervention.

Choice D rationale

Preparing for mechanical ventilation is not the most appropriate next step. While the client’s decreased oxygen saturation and increased respiratory rate suggest respiratory distress, the priority should be to address the potential pulmonary embolism. Mechanical ventilation may be necessary later depending on the client’s response to treatment.

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Correct Answer is D

Explanation

Choice A rationale

While obtaining a full set of vital signs is an important part of assessing a patient’s condition, it should not be the initial action in this case. The symptoms described by the patient suggest hypoglycemia, which requires immediate confirmation and treatment.

Choice B rationale

Administering 1 mg glucagon subcutaneously is not the initial action. Glucagon is used to treat severe hypoglycemia when the patient is unable to take glucose orally. However, the patient’s blood glucose level should be checked first.

Choice C rationale

Administering 25 mL of 50% dextrose is not the initial action. This treatment is used for severe hypoglycemia, but the patient’s blood glucose level should be checked first to confirm hypoglycemia.

Choice D rationale

Obtaining a blood glucose reading is the correct initial action. The symptoms described by the patient suggest hypoglycemia. Checking the blood glucose level will confirm whether the patient is hypoglycemic and needs treatment.

A. Pseudomembranous colitis and crystalluria. B. Headaches, vertigo, and tinnitus. C. Headache and potassium 3.5 mg/dL. D. Hypoglycemia and cardiac dysrhythmias.

Correct Answer is B

Explanation

Choice A rationale

Pseudomembranous colitis and crystalluria are not typically associated with gentamicin use.

Choice B rationale

Gentamicin can cause ototoxicity, which can manifest as tinnitus (ringing in the ears), vertigo (a sensation of spinning), and hearing loss. Headaches can also occur as a side effect of gentamicin.

Choice C rationale

While gentamicin can cause nephrotoxicity (kidney damage), which could potentially affect electrolyte levels, a potassium level of 3.5 mg/dL is within the normal range. Therefore, this would not typically be assessed as a toxic effect of gentamicin.

Choice D rationale

Hypoglycemia and cardiac dysrhythmias are not typically associated with gentamicin use.

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Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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Naxlex Comprehensive Predictor Exams

A patient is recovering from an episode of diabetic ketoacidosis and reports feeling “anxious, shaky, and sweaty.”. What should be the nurse’s initial action?

Correct Answer is D

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

The nurse is monitoring a client receiving gentamicin. Which of the following would the nurse assess as potential toxic effects of this medication?

Correct Answer is B

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The nurse is caring for a patient with a diagnosis of chronic peripheral arterial disease. Which statement by the patient warrants immediate intervention by the nurse?

Which clinical manifestation should the nurse anticipate as an expected finding for a client diagnosed with deep vein thrombosis (DVT)?

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