a client is in the emergency room in critical condition and hypotensive her spouse is distraught what is the priority nursing action

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A client is in the emergency room in critical condition and hypotensive. Her spouse is distraught. What is the priority nursing action?

A. Maintain the client's blood pressure
B. Call a chaplain
C. Provide the spouse a chair
D. Ask the client's spouse to explain what happened

Correct answer: A

Rationale:

2. The nurse is preparing to administer medications to a client with osteoarthritis. What is the goal of medication therapy?

A. Eradicate the disease
B. Reduce pain and inflammation
C. Turn on the immune system
D. Manage weight loss

Correct answer: B

Rationale:

3. A client on bed rest complains of pain and burning in the right calf area. What is the nurse's action?

A. Deeply palpate the area for rebound tenderness
B. Medicate the client for pain and reassess in 60 minutes
C. Percuss over the area for a change in tone
D. Compare the circumference to the left calf

Correct answer: D

Rationale:

4. The nurse is caring for 4 clients. What client should the nurse see first?

A. A client with multiple children visiting
B. A client with lupus asking for dinner
C. A client on Methotrexate with a fever
D. A client with chronic rheumatic pain

Correct answer: C

Rationale: The correct answer is the client on Methotrexate with a fever. Fever in a client on Methotrexate, an immunosuppressant, could indicate a serious infection or adverse drug reaction requiring immediate attention to prevent complications. The other choices do not present immediate life-threatening concerns. A client with lupus asking for dinner can wait, a client with chronic rheumatic pain may need pain management but is not the priority over a fever in a client on Methotrexate, and a client with children visiting does not pose an urgent medical issue.