Difficulty: Medium
Average Score: 79%
Simulated
Passage / Scenario
Vital Signs (0610): Oral temperature: 36.6├é┬░C (97.9├é┬░F), Heart rate: 120/min, Respiratory rate: 22/min, Blood pressure: 86/48 mm Hg, SaO├óÔÇÜÔÇÜ: 96% on room air. Nurses' Notes (0630): The client appears anxious and reports dizziness. She has pale skin and cool extremities. Her abdomen is soft and non-tender with no palpable contractions. She reports no vaginal bleeding or discharge. Deep tendon reflexes are 2+. Peripheral edema is 1+ in bilateral lower extremities. The client is also noted to have tachycardia. Diagnostic Results: Hematocrit (Hct): 25% (normal: >33%), Hemoglobin (Hgb): 9 g/dL (normal: >11 g/dL), Maternal blood type: B+, Platelet count: 110,000/mm├é┬│ (normal: 150,000 to 400,000/mm├é┬│), WBC count: 12,000/mm├é┬│ (normal: 5,000 to 10,000/mm├é┬│).Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Correct answer
A
Rationale
An ectopic pregnancy is most likely due to the combination of symptoms: dizziness, pale skin, cool extremities, low blood pressure (86/48 mm Hg), and high heart rate (120/min). Actions: Administer methotrexate to stop embryo growth; insert a large-bore peripheral IV catheter to manage blood loss. Parameters: Monitor beta hCG levels to confirm diagnosis; monitor platelet count due to bleeding risk.