Difficulty: Medium
Average Score: 69%
Simulated
Passage / Scenario
Vital Signs1500:
Heart rate 52/min
Respiratory rate 28/min)
Blood pressure 74/50 mm Hg
Temperature 36.1┬░ C (97┬░ F)
Sa02 90% on 2 L/min via nasal cannula
Nurses Notes
1515:
Client arrived at the ED via ambulance. Emergency medical technicians (EMTS) state the client fainted at place of employment while walking down a flight of stairs. Client fell and rolled down several steps. Coworkers called for an ambulance. Client was awake upon EMTs arrival. Client oriented to person, place, time, but appears lethargic. Reports dizziness and headache. No injury noted from fall. Client states, "I think I just haven't eaten enough today. That must be why I passed out." Client states they have passed out numerous times in the past month. Reports only eating one meal a day for the past few months because they have been "dieting"
Client is thin and appears emaciated with diminished muscle mass.
Skin is cold, dry, poor turgor, mottled with bluish tint to extremities Lanugo present to arms
S1 S2 heard on auscultation, peripheral pulses weak
Respirations rapid, labored. Client reports feeling short of breath. Chest clear on auscultation.
Bowel sounds hypoactive x 4 quadrants. Cannot recall last bowel movement. States ÔÇ£IÔÇÖve been constipated lately.ÔÇØ
Reports no difficulty with urination. Urine obtained for urinalysis and is dark, concentrated.
A nurse in the emergency department (ED) is caring for a client. Laboratory Results Exhibits: Complete the following sentence by using the list of options.The nurse should first address the client------------- followed by the client ----------------
Correct answer
B,A
Rationale
Action to Take: B, A; Potential Condition: Hypotension; Parameter to Monitor: Urine output, Oxygen saturation.
Rationale: The correct actions to take first would be addressing the client's blood pressure (B) as hypotension can be life-threatening in an emergency setting. This should be followed by addressing the client's oxygenation (A) as inadequate oxygenation can also lead to serious complications. Monitoring the client's urine output is crucial to assess renal function in response to hemodynamic changes, and monitoring oxygen saturation helps ensure adequate tissue oxygenation. Addressing the other choices would be important too, but not as immediate and critical in this scenario.
Rationale: The correct actions to take first would be addressing the client's blood pressure (B) as hypotension can be life-threatening in an emergency setting. This should be followed by addressing the client's oxygenation (A) as inadequate oxygenation can also lead to serious complications. Monitoring the client's urine output is crucial to assess renal function in response to hemodynamic changes, and monitoring oxygen saturation helps ensure adequate tissue oxygenation. Addressing the other choices would be important too, but not as immediate and critical in this scenario.