The nurse receives information about the assigned patients during shift report.
Which patient would the nurse assess first?

A patient who reports dizziness with a blood pressure (BP) of 150/92 mm Hg.

A patient who reports a severe headache and has begun vomiting.

A patient with a hip fracture who reports a pain level of 2 on a 1-to-10 scale.

A patient who received an angiotensin-converting enzyme (ACE) inhibitor 30 minutes previously and reports fatigue.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Dizziness with a blood pressure of 150/92 mm Hg indicates hypertension, but it is not an immediate life-threatening condition requiring urgent assessment compared to a severe headache and vomiting.

Choice B rationale:

A severe headache and vomiting could be indicative of a serious neurological condition such as a stroke, intracranial bleeding, or increased intracranial pressure. This patient needs urgent assessment and intervention to prevent potential complications.

Choice C rationale:

A hip fracture with a pain level of 2 on a 1-to-10 scale suggests pain but is not immediately life-threatening compared to symptoms like severe headache and vomiting.

Choice D rationale:

Fatigue after receiving an ACE inhibitor is a common side effect and, while important to monitor, does not pose an immediate threat compared to the symptoms of severe headache and vomiting.

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Correct Answer is C

Explanation

Choice A rationale: Drinking 14 glasses of water daily is not specifically harmful for patients with thrombocytopenia, though it is important to ensure fluid intake is balanced with the individual's needs. However, excessive water intake is generally not related to increased bleeding risks, which is a primary concern for patients with low platelet counts.

Choice B rationale: Shaving once a day using an electric razor is an appropriate precaution for patients with thrombocytopenia. Electric razors are less likely to cause cuts compared to traditional razors, thereby reducing the risk of bleeding. This measure is important for individuals with low platelet counts to minimize the risk of bleeding from minor injuries.

Choice C rationale: Using an alcohol-based mouthwash twice a day is not recommended for patients with thrombocytopenia. Alcohol-based mouthwash can cause dryness and irritation of the mucous membranes, which may lead to bleeding, especially in individuals with low platelet counts. Instead, non-alcoholic mouthwashes should be used to maintain oral hygiene without the risk of causing mucosal damage.

Choice D rationale: Brushing teeth with a soft-bristle toothbrush twice a day is recommended for patients with thrombocytopenia. Soft-bristle toothbrushes help reduce the risk of gum injury and bleeding, which is important for individuals with low platelet counts. Maintaining good oral hygiene with minimal trauma is crucial for these patients

A. Metabolic acidosis. B. Metabolic alkalosis. C. Respiratory acidosis. D. Respiratory alkalosis.

Correct Answer is B

Explanation

Choice A rationale:

Metabolic acidosis is characterized by a low pH (<7.35) and a low bicarbonate level (<22 mEq/L) The given arterial blood gas (ABG) values indicate a pH of 7.48 (which is alkalotic), a PaCO2 of 38 (within the normal range of 35-45 mm Hg), and an HCO3- of 30 (which is elevated) These values indicate metabolic alkalosis, not metabolic acidosis.

Choice B rationale:

Metabolic alkalosis is characterized by a high pH (>7.45) and an elevated bicarbonate level (>26 mEq/L) The given ABG values indicate a pH of 7.48 (which is alkalotic) and an elevated HCO3- of 30, indicating metabolic alkalosis. This condition can result from excessive loss of acids (e.g., vomiting) or excessive intake of bicarbonate or alkali substances.

Choice C rationale:

Respiratory acidosis is characterized by a low pH (<7.35) and a high PaCO2 (>45 mm Hg) The given ABG values indicate a normal pH of 7.48 and a PaCO2 of 38 (within the normal range), ruling out respiratory acidosis.

Choice D rationale:

Respiratory alkalosis is characterized by a high pH (>7.45) and a low PaCO2 (<35 mm Hg) The given ABG values indicate a pH of 7.48 (which is alkalotic) and a PaCO2 of 38 (within the normal range), ruling out respiratory alkalosis.

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The nurse receives information about the assigned patients during shift report.Which patient would the nurse assess first?

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Naxlex Comprehensive Predictor Exams

The nurse provides education to a patient with thrombocytopenia about precautions to be taken at home. The nurse identifies that further teaching is needed when the patient performs which action?

Correct Answer is C

Explanation

A patient's arterial blood gas (ABG) values include a pH of 7.48, a PaCO2 of 38, and an HCO3- of 30. Around which acid-base imbalance would the nurse plan the patient's care?

Correct Answer is B

Explanation

In which type of water would a submersion injury cause the patient's fluid to be drawn from the vascular space into the alveoli, impairing alveolar ventilation and resulting in hypoxia?

A patient reports leg pain that awakens the patient at night.The patient reports that the same pain develops in the legs when they are elevated and disappears when the legs are dangled.Which condition would the nurse suspect?

Which manifestation is related to target organ disease from hypertension? Select all that apply.One, some, or all responses may be correct.

Which information would the nurse include when discussing pain due to chronic stable angina with the patient?

A female patient with chronic hypertension is admitted to the emergency department with a sudden rise in blood pressure (BP) Which question is the priority for the nurse to ask the patient?

Which laboratory report finding would support the nurse's conclusion that a patient has thalassemia major? Select all that apply.One, some, or all responses may be correct.

The arterial blood gas (ABG) results for a patient who overdosed on barbiturates are pH = 7.32, PaCO2 = 52, and HCO3 = 23. Which interpretation would the nurse rely on when planning the patient's care?

Which information would the nurse include when discussing pain due to chronic stable angina with the patient?

The nurse receives information about the assigned patients during shift report.
Which patient would the nurse assess first?