Nokea
The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 5 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.
Click to highlight the orders that the nurse should consider a priority.
- A. Perform admission medication reconciliation and admit the client to the intensive care unit
- B. Remove the client's clothing
- C. Start a large-bore peripheral vascular access device
- D. 0.9% sodium chloride (normal saline) 1000 mL, IV, once
- E. Obtain medical records from the client's outpatient primary healthcare provider
- F. Insert temperature-sensing indwelling urinary catheter
- G. Apply a cooling blanket to the client
Correct Answer: B,C,D,F,G
Rationale: Priority orders address immediate life-threatening issues: removing clothing (B), IV access (C), saline (D), temperature catheter (F), and cooling blanket (G) manage heat stroke and hypotension. Medication reconciliation (A) and medical records (E) are secondary.
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A nurse is assessing a client with a urinary tract infection who takes an antihypertensive drug. The nurse reviews the client’s urinalysis results (see chart). The nurse should:
- A. Encourage the client to increase fl uid intake.
- B. Withhold the next dose of antihypertensive medication.
- C. Restrict the client’s sodium intake.
- D. Encourage the client to eat at least half of a banana per day
Correct Answer: A
Rationale: The client’s urine specifi c gravity is elevated. Specific gravity is a refl ection of the concentrating ability of the kidneys. This level indicates that the urine is concentrated. By increasing fluid intake, the urine will become more dilute. Antihypertensives do not make urine more concentrated unless there is a diuretic component within them. The nurse should not hold a dose of antihypertensive medication. Sodium tends to pull water with it; by restricting sodium, less water, not more, will be present. Bananas do not aid in the dilution of urine.
The nurse is planning care for a client who had surgery for abdominal aortic aneurysm repair 2 days ago. The pain medication and the use of relaxation and imagery techniques are not relieving the client's pain and the client refuses to get out of bed to ambulate as ordered. The nurse contacts the physician, explains the situation, and provides information about drug dose, frequency of administration, the client's vital signs, and the client's score on the pain scale. The physician tells the nurse that the current order for pain medication is sufficient and the client will be fine in a few days. The nurse should next:
- A. Explain to the physician that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as ordered
- B. Ask the hospitalist to write an order for a stronger pain medication
- C. Wait until the next shift and ask the nurse on that shift to contact the physician
- D. Report the incident to the team leader
Correct Answer: A
Rationale: The nurse should advocate for the client by reiterating to the physician that the current pain management is ineffective, preventing ambulation, which is critical for recovery post-AAA repair. This aligns with ethical and professional standards. Asking another provider, waiting, or reporting to the team leader delays care.
The physician ordered I.V. naloxone (Narcan) to reverse the respiratory depression from morphine administration. After administration of the naloxone the nurse should:
- A. Check respirations in 5 minutes because naloxone is immediately effective in relieving respiratory depression.
- B. Check respirations in 30 minutes because the effects of morphine will have worn off by then.
- C. Monitor respirations frequently for 4 to 6 hours because the client may need repeated doses of naloxone.
- D. Monitor respirations each time the client receives morphine sulfate 10 mg I.M.
Correct Answer: C
Rationale: Naloxone has a shorter half-life than morphine, so respiratory depression may recur. Frequent monitoring for 4-6 hours ensures timely detection and additional doses if needed.
A client who underwent a lobectomy and has a water-seal chest drainage system is breathing with a little more effort and at a faster rate than 1 hour ago. The client's pulse rate is also increased. The nurse should:
- A. Check the tubing to ensure that the client is not lying on it or kinking it.
- B. Increase the suction.
- C. Lower the drainage bottles 2 to 3 feet below the level of the client's chest.
- D. Ensure that the chest tube has two clamps on it to prevent air leaks.
Correct Answer: A
Rationale: Increased respiratory effort, rate, and pulse suggest a possible obstruction; checking for kinked or compressed tubing is the first step. Increasing suction, lowering bottles, or clamping tubes risks worsening the issue.
Which of the following findings would most likely indicate the presence of a respiratory infection in a client with asthma?
- A. Cough productive of yellow sputum.
- B. Bilateral expiratory wheezing.
- C. Chest tightness.
- D. Respiratory rate of 30 breaths/minute.
Correct Answer: A
Rationale: A productive cough with yellow sputum suggests a respiratory infection, which can exacerbate asthma. Wheezing, chest tightness, and tachypnea are typical asthma symptoms, not specific to infection.