The nurse is reviewing a newly admitted client's electronic health record, which notes a history of orthopnea. What nursing action is most clearly indicated?

Avoid positioning the client supine.

Limit the client's activity level.

Administer supplemental oxygen at all times.

Teach the client deep breathing and coughing exercises.

Answer and Explanation

The Correct Answer is A

A. Avoid positioning the client supine: Orthopnea is the inability to breathe comfortably while lying flat, so the nurse should avoid placing the client in a supine position and instead elevate the head of the bed.

B. Limit the client's activity level: While activity may need to be adjusted, this is not the primary concern for orthopnea.

C. Administer supplemental oxygen at all times: Oxygen may be necessary, but the key issue with orthopnea is the need to avoid lying flat, not necessarily the need for constant supplemental oxygen.

D. Teach the client deep breathing and coughing exercises: While beneficial for other conditions, this does not directly address orthopnea, which is primarily positional.

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Correct Answer is ["15.94"]

Explanation

Convert the ordered dose to mcg/min:

10 mcg/kg/min × 85 kg = 850 mcg/min

Convert the available dose to mcg/mL:

800 mg = 800,000 mcg in 250 mL

Concentration = 800,000 mcg ÷ 250 mL

= 3200 mcg/mL

Calculate the infusion rate:

Infusion rate (mL/hour) = [Desireddose(mcg/min) ÷Concentration(mcg/mL)] ×60 min/hour

Infusion rate = (850 mcg/min ÷ 3200 mcg/mL) × 60 min/hour

= 15.94 mL/hour

The IV pump should be set to infuse at approximately 15.94 mL/hour to deliver the ordered dose of dopamine at 10 mcg/kg/min for a patient weighing 85 kg. This ensures the appropriate therapeutic effect.

A. Administer a stat fluid challenge B. Place the patient in a prone position C. Draw a stat CBC D. Perform a stat pericardiocentesis

Correct Answer is D

Explanation

A. Administer a stat fluid challenge: This might temporarily improve cardiac output in tamponade, but it is not the primary intervention. The fluid challenge may be used as a temporary measure, but it does not address the underlying cause.

B. Place the patient in a prone position: This is incorrect and could worsen the patient's condition. The patient should be in a semi-recumbent position to decrease venous return and reduce pressure on the heart.

C. Draw a stat CBC: A CBC is not relevant to the immediate management of cardiac tamponade and does not address the urgent need to relieve the pressure on the heart.

D. Perform a stat pericardiocentesis: Pericardiocentesis is the definitive treatment for cardiac tamponade, as it removes the fluid from the pericardial space, relieving the pressure on the heart and allowing it to function properly.

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The nurse is reviewing a newly admitted client's electronic health record, which notes a history of orthopnea. What nursing action is most clearly indicated?

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Naxlex Comprehensive Predictor Exams

The physician orders dopamine at 10 mcg/kg/min. The pharmacy provides dopamine 800mg in 250 ml of D5W. What is the hourly IV pump rate? The patient weighs 85 kilograms. Order: Dopamine at 10 mcg/kg/min Available: Dopamine 800 mg in 250 mL D5W Patient weight: 85 kg

Correct Answer is ["15.94"]

Explanation

A patient is brought to the ED after being struck by a baseball to the chest. The physician suspects a cardiac tamponade based on hypotension muffled heart sounds, and distended jugular veins. What is the primary intervention for this patient?

Correct Answer is D

Explanation

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