Master Your NCLEX® with Expert Guidance

A. Capillary refill in the affected limb is less than 2 seconds: Incorrect. Normal capillary refill suggests adequate perfusion.

B. The patient reports mild tenderness at the puncture site: Incorrect. Mild tenderness is expected after an angioplasty.

C. The patient’s pulse distal to the puncture site is weak: Correct. Weak distal pulses indicate possible arterial occlusion or compromised blood flow, requiring immediate intervention.

D. The patient reports mild numbness in the affected leg: Incorrect. Mild numbness may result from post-procedure immobility, but weak pulses are more urgent.

Rationale: Currant jelly stools consisting of blood and mucus are a hallmark sign of intussusception. Frequent watery stools are more indicative of gastroenteritis. A painful abdominal mass may occur but is not specific to intussusception.

A. Administer sublingual nitroglycerin: Incorrect. Nitroglycerin may further lower BP in this hypotensive patient and should be used cautiously.

B. Start oxygen at 2 L/min via nasal cannula: Correct. Oxygen improves myocardial oxygenation and reduces ischemia.

C. Prepare the patient for PCI: Correct. PCI is the definitive treatment for ST-elevation myocardial infarction (STEMI).

D. Obtain blood samples for cardiac enzymes: Correct. Cardiac biomarkers confirm myocardial infarction.

E. Administer morphine for pain relief: Correct. Morphine relieves pain and reduces myocardial oxygen demand.

A. Initiate high-flow oxygen therapy at 10 L/min: Incorrect. High oxygen can suppress the respiratory drive in COPD patients with chronic hypercapnia.

B. Perform pursed-lip breathing exercises with the patient: Incorrect. Helpful for CO2 elimination but not the immediate priority.

C. Prepare the patient for intubation: Incorrect. Intubation is indicated only in severe respiratory distress.

D. Administer bronchodilators as prescribed: Correct. Bronchodilators reduce airway resistance, improving oxygenation and carbon dioxide elimination.

A. Check the client’s blood pressure: Correct. These are signs of autonomic dysreflexia, which causes severe hypertension.

B. Administer antihypertensive medication immediately: Incorrect. First, identify and remove the stimulus (e.g., bladder distention).

C. Elevate the head of the bed: Correct. Reduces BP by promoting venous pooling.

D. Assess for bladder distention: Correct. A full bladder is a common trigger for autonomic dysreflexia.

E. Notify the healthcare provider after initial interventions: Correct. Ensures the provider is updated after emergency measures.

A. Urine output increases to 30 mL/hour: Correct. Indicates improved renal perfusion.

B. Lactate level decreases from 5 mmol/L to 2 mmol/L: Correct. A decrease in lactate shows improved tissue oxygenation.

C. Heart rate increases from 110 bpm to 130 bpm: Incorrect. Tachycardia worsening suggests persistent hypoperfusion.

D. Blood pressure increases to 90/60 mmHg: Correct. A target BP indicates better organ perfusion in septic shock.

E. Capillary refill improves to less than 2 seconds: Correct. Indicates better peripheral circulation.

Rationale: Digoxin slows the heart rate and improves contractility. The nurse must assess the apical pulse for 1 minute and withhold the medication if the pulse is below 60 beats per minute.

A. Administer IV regular insulin: Correct. Insulin is essential to lower blood glucose and correct acidosis.

B. Provide a high-protein diet: Incorrect. Clients in DKA are typically NPO until stabilized; protein would not address the acute metabolic issue.

C. Infuse normal saline as prescribed: Correct. Rehydration with isotonic fluids is a priority to correct hypovolemia.

D. Monitor potassium levels closely: Correct. Potassium shifts during insulin therapy can lead to hypokalemia, requiring close monitoring.

E. Administer IV sodium bicarbonate for all clients: Incorrect. Bicarbonate is only given in severe acidosis (pH < 7.0) to prevent complications.

A. Administer aspirin: Incorrect. Aspirin is indicated but not in the acute phase when tPA is a possibility.

B. Prepare for administration of alteplase (tPA): Correct. tPA must be given within 3-4.5 hours of symptom onset to dissolve the clot and restore perfusion.

C. Elevate the head of the bed to 45 degrees: Incorrect. Head elevation should be minimal (15-30 degrees) to optimize cerebral perfusion.

D. Initiate IV fluids to maintain hydration: Incorrect. Hydration is important but secondary to tPA administration.

A. Administer the digoxin and monitor heart rate: Incorrect. A heart rate below 60 bpm is a contraindication for digoxin administration.

B. Hold the digoxin and notify the provider: Correct. Bradycardia and borderline hypokalemia increase the risk of digoxin toxicity.

C. Administer potassium supplements before digoxin: Incorrect. Requires provider notification and specific potassium orders.

D. Increase the patient’s fluid intake: Incorrect. Fluid intake does not address the immediate concern of bradycardia or digoxin toxicity.