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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Serotonin is a neurotransmitter that plays a role in mood regulation, sleep, and other functions in the body. It is not a component that forms an adhesive bridge between platelets and vascular subendothelial structures in the clotting process.
Choice B rationale:
Platelet factor III is not a component that forms an adhesive bridge between platelets and vascular subendothelial structures in the clotting process. Platelet factor III is not widely recognized in the context of clotting; it is more commonly referred to as tissue factor and is involved in the extrinsic pathway of coagulation.
Choice C rationale:
Von Willebrand factor (VWF) is a protein that plays a crucial role in hemostasis. It forms an adhesive bridge between platelets and vascular subendothelial structures, particularly at sites of vascular injury. VWF helps platelets adhere to the injured vessel wall, leading to the formation of a stable blood clot. This process is essential for preventing excessive bleeding. A deficiency or dysfunction in VWF can lead to von Willebrand disease, a bleeding disorder characterized by prolonged bleeding times.
Choice D rationale:
Adenosine diphosphate (ADP) is a molecule released by platelets when they are activated. ADP helps in the aggregation of platelets, but it does not directly form an adhesive bridge between platelets and vascular subendothelial structures.
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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