Which of the following actions should the nurse take immediately?
(Select the 4 actions the nurse should take.)
Administer oxygen
Obtain prescription for amiodarone
Place client in semiFowler's position
Monitor blood pressure every 30 minutes
Obtain prescription for a beta blocker
Monitor for neurologic complications
Correct Answer : A,C,E,F
Rationale:
A. Administer oxygen: The client is experiencing labored respirations and increasing distress. Although their oxygen saturation is currently within normal range, supplemental oxygen is a priority to support oxygenation during this acute episode, especially with signs of anxiety and shortness of breath.
B. Obtain prescription for amiodarone: Amiodarone is used for certain ventricular arrhythmias. The client’s heart rhythm is described as regular, though tachycardic, not indicating a need for amiodarone. This is not an immediate priority without evidence of a specific arrhythmia like ventricular tachycardia.
C. Place client in semi-Fowler's position: Elevating the head of the bed helps reduce the work of breathing and improves lung expansion. This position supports respiratory function, especially when the client is experiencing shortness of breath.
D. Monitor blood pressure every 30 minutes: Blood pressure monitoring is important, but this action is not immediate in the face of worsening symptoms. The client needs more urgent interventions first, including respiratory and cardiac stabilization.
E. Obtain prescription for a beta blocker: The client’s heart rate increased significantly to 170/min and they have a history of poorly controlled hypertension. A beta blocker may be needed to reduce sympathetic overactivity and heart rate, helping to lower blood pressure and myocardial oxygen demand.
F. Monitor for neurologic complications: With a blood pressure of 185/100 mmHg and a worsening severe headache, the client is at risk for neurologic complications such as hypertensive encephalopathy or stroke. Close neurologic monitoring is essential to detect early signs of deterioration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. N95 respirator: N95 respirators are required for airborne precautions, such as with tuberculosis, measles, or varicella. Bacterial meningitis, caused by organisms like Neisseria meningitidis, requires droplet precautions, which do not necessitate an N95 mask.
B. Goggles: Goggles are used for protection against splashes or sprays of bodily fluids, particularly in procedures that may cause aerosolization. While helpful in certain situations, goggles are not required as part of standard droplet precautions for meningitis.
C. Disposable gown: Gowns are worn during contact precautions or when there is a risk of contamination from bodily fluids. They are not routinely required for droplet precautions unless the nurse anticipates contact with large amounts of secretions.
D. Surgical mask: A surgical mask is the appropriate PPE for droplet precautions, which are necessary for clients with bacterial meningitis. The mask prevents the spread of infectious respiratory droplets that can travel up to 3 feet during coughing or sneezing.
Correct Answer is B
Explanation
Rationale:
A. Use a 3 mL syringe to flush the PICC following infusions: A syringe smaller than 10 mL creates excessive pressure, which can damage the catheter. A 10 mL syringe or larger should always be used to flush a PICC to maintain catheter integrity.
B. Assess the PICC infusion system systematically: Systematic assessment of the PICC line, including the site, tubing, and connections, is essential for detecting complications such as infiltration, infection, or occlusion. This promotes safe and effective use of the catheter.
C. Change the needleless connector device on the IV tubing after each infusion: The needleless connector device does not need to be changed after each infusion. It is typically changed every 7 days or if contamination, leakage, or other issues are noted.
D. Provide daily dressing changes to the PICC insertion site: PICC dressings should be changed every 7 days if using a transparent dressing, or sooner if the dressing becomes damp, loose, or visibly soiled. Daily dressing changes increase infection risk unnecessarily.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.