Complex Situations NCLEX

A triage nurse encounters a client who complained of mid-sternal chest pain, dizziness, and diaphoresis. Which of the following nursing action should take priority?

• Notify the physician

• Administer oxygen therapy via nasal cannula

• Complete history taking

• Put the client on ECG monitoring

Answer explanation

The priority goal is to increase myocardial oxygenation. Place the patient on a cardiac monitor, establish intravascular access (IV) access, give 162 mg to 325 mg chewable aspirin, clopidogrel, or ticagrelor (unless bypass surgery is imminent), control pain and consider oxygen (O2) therapy. (Wayne, 2022)

A 3-year-old child was brought to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling, and suprasternal retractions. What should the nurse do first?

• Prepare the child for X-ray of upper airways

• Examine the child’s throat

• Collect a sputum specimen

• Notify the healthcare provider of the child’s status

Answer explanation

These findings suggest a medical emergency and may be due to epiglottitis. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate care.

Option A: If epiglottitis is seriously considered, no imaging studies are required. In less-clear cases, imaging studies are occasionally helpful in establishing the diagnosis or excluding epiglottitis.

Option B: Examining the child’s throat should not be attempted because it may compromise respiratory effort.

Option C: There are no indications for the collection of sputum specimens.

(Vera, 2023)

A patient’s chart indicates a history of ketoacidosis. Which of the following would you NOT expect to see with this patient if this condition were acute?

• Vomiting

• Acetone breath smell

• Weight gain

• Extreme Thirst

Answer explanation

Rapid weight loss occurs in patients newly diagnosed with type 1 diabetes. In people with diabetes, insufficient insulin prevents the body from getting glucose from the blood into the body’s cells to use as energy. When this occurs, the body starts burning fat and muscle for energy, causing a reduction in overall body weight.

(Vera, 2022)

A nurse enters a client’s room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is:

• Start a peripheral IV

• Initiate high-quality chest compressions

• Establish an airway

• Obtain the crash cart

Answer explanation

As per new guidelines, the American Heart Association recommends beginning CPR with chest compression (rather than checking for the airway first). Start CPR with 30 chest compressions before checking the airway and giving rescue breaths. Starting with chest compressions first applies to adults, children, and infants needing CPR, but not newborns. CPR can keep oxygenated blood flowing to the brain and other vital organs until more definitive medical treatment can restore a normal heart rhythm.

Option A: Starting a peripheral IV can come after the C-A-B sequence.

Option C: Establishing an airway comes after compressions.

Option D: After performing the guidelines by the AHA, the crash cart can be obtained by another nurse responding to the scene.

(Vera, 2023)

A 20-year-old female attending college is found unconscious in her dorm room. She has a fever and a noticeable rash. She has just been admitted to the hospital. Which of the following tests is most likely to be performed first?

• Blood cultures

• Arterial Blood Gases

• Head CT

• ECG test

Answer explanation

Blood cultures would be performed to investigate the fever and rash symptoms. A blood culture is a test that checks for foreign invaders like bacteria, yeast, and other microorganisms in the blood. Having these pathogens in the bloodstream can be a sign of a blood infection, a condition known as bacteremia. A positive blood culture means that there are bacteria in the blood.

(Vera, 2023)