Question

A nurse is preparing to administer metoprolol 5 mg IV bolus to a client for heart rate control. Available is metoprolol injection 1 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Answer 1

Correct Answers:

5

Rationale :

💎 Ordered dose = 5 mg, and available concentration = 1 mg per 1 mL.

💎 Calculation: 5 mg divided by 1 mg per mL = 5 mL.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Airway protection

Rationale :

🚑 Airway protection is the highest priority because adequate oxygenation is essential for survival and follows the ABC (Airway, Breathing, Circulation) principle in trauma care.

🚑 In multiple system trauma, airway obstruction can rapidly occur due to facial injuries, bleeding, swelling, or decreased level of consciousness.

🚑 Without a patent airway, oxygen cannot reach the lungs, leading to hypoxia, organ failure, and cardiac arrest within minutes.

🚑 Establishing and maintaining airway patency may require positioning, suctioning, oxygen administration, or endotracheal intubation.

🚑 According to Advanced Trauma Life Support (ATLS) guidelines, airway management is always assessed and secured before addressing other life-threatening conditions.

Incorrect Options

Stabilizing cardiac arrhythmias

🚑 Cardiac rhythm abnormalities are important but are addressed after airway and breathing are secured.

🚑 Treating arrhythmias without ensuring oxygenation does not correct the underlying hypoxia.

Decreasing intracranial pressure

🚑 Managing intracranial pressure is critical in head trauma cases.

🚑 However, oxygen delivery must be ensured first because hypoxia worsens brain injury.

Preventing musculoskeletal disability

🚑 Orthopedic injuries are significant for long-term outcomes.

🚑 They are not immediately life-threatening compared to airway compromise.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Skin tenting present

Rationale :

💧 Skin tenting present indicates decreased skin elasticity, which is a classic clinical sign of dehydration.

💧 When the body loses significant fluid volume, interstitial fluid decreases, reducing skin turgor and causing the skin to remain elevated after being pinched.

💧 Dehydration results in extracellular fluid deficit, leading to poor tissue perfusion and diminished elasticity.

💧 This finding is especially noticeable over the sternum or forearm in adults.

💧 Identifying skin tenting early allows prompt fluid replacement to prevent progression to hypovolemia and shock.

Incorrect Options

Jugular vein distention

💧 Jugular vein distention typically indicates fluid volume overload or right-sided heart failure.

💧 Dehydration usually presents with flat neck veins rather than distended ones.

Blood pressure 178/90 mm Hg

💧 Hypertension suggests increased vascular resistance or fluid excess.

💧 Dehydration more commonly leads to hypotension, particularly orthostatic hypotension.

Low body temperature

💧 Low body temperature may occur in exposure or metabolic conditions.

💧 It is not a primary or specific indicator of dehydration.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

The nurse starts the transfusion of another unit of blood product.

Rationale :

🩸 Starting another unit of blood after a suspected hemolytic transfusion reaction is unsafe and contraindicated.

🩸 In a suspected acute hemolytic reaction, the priority is to stop the transfusion immediately and maintain IV access with normal saline using new tubing.

🩸 Restarting any blood product before investigation increases the risk of worsening hemolysis, renal failure, shock, and disseminated intravascular coagulation (DIC).

🩸 The blood bank must first be notified and compatibility testing performed before any further transfusion is considered.

🩸 Continuing or restarting blood products without provider clearance demonstrates unsafe clinical judgment and requires immediate intervention.

Incorrect Options

The nurse collects a urine specimen.

🩸 Collecting urine is appropriate to assess for hemoglobinuria, which indicates intravascular hemolysis.

🩸 This action supports evaluation of kidney involvement and is part of standard protocol.

The nurse sends a blood specimen to the laboratory.

🩸 Sending a blood sample helps confirm hemolysis and check for clerical or compatibility errors.

🩸 This is an appropriate and expected intervention.

The nurse initiates an infusion of 0.9% sodium chloride.

🩸 Infusing normal saline maintains IV patency and supports blood pressure.

🩸 It also helps flush free hemoglobin through the kidneys to reduce renal damage.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Hypovolemic shock

Rationale :

🩺 Hypovolemic shock occurs when there is a significant loss of circulating blood volume, leading to inadequate tissue perfusion.

🩺 The client lost 800 mL of blood, which reduces preload, decreases stroke volume, and ultimately lowers cardiac output.

🩺 A steadily decreasing blood pressure over 2 hours indicates progressive circulatory compromise due to volume depletion.

🩺 In hypovolemic shock, the body attempts to compensate through tachycardia and vasoconstriction, but without fluid replacement, hypotension worsens.

🩺 Postoperative blood loss is a classic cause of hemorrhagic hypovolemic shock, requiring rapid fluid resuscitation and possible blood product replacement.

Incorrect Options

Neurogenic shock

🩺 Neurogenic shock results from loss of sympathetic tone, typically due to spinal cord injury.

🩺 It presents with hypotension and bradycardia rather than blood loss as the primary cause.

Obstructive shock

🩺 Obstructive shock occurs when blood flow is physically blocked, such as in pulmonary embolism or cardiac tamponade.

🩺 There is no indication of mechanical obstruction in this scenario.

Septic shock

🩺 Septic shock results from systemic infection leading to vasodilation and inflammatory response.

🩺 This client’s declining blood pressure is directly related to acute blood loss, not infection.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Troponin

Rationale :

❤️ Troponin is the most specific and sensitive biomarker for myocardial injury and is the primary laboratory test used to diagnose myocardial infarction (MI).

❤️ When cardiac muscle cells are damaged due to ischemia, cardiac troponin I and T are released into the bloodstream.

❤️ Troponin levels begin to rise within 3–6 hours after myocardial injury and can remain elevated for 7–14 days.

❤️ Elevated troponin confirms myocardial cell necrosis and helps differentiate MI from other causes of chest pain.

❤️ Because of its high specificity for cardiac tissue, troponin has replaced other markers as the gold standard for MI diagnosis.

Incorrect Options

Creatinine kinase (CK)

❤️ CK, particularly CK-MB, was previously used to detect myocardial injury.

❤️ However, it is less specific than troponin and can also rise with skeletal muscle damage.

Brain natriuretic peptide (BNP)

❤️ BNP is primarily used to evaluate heart failure by assessing ventricular stretch.

❤️ It does not specifically diagnose myocardial infarction.

C-reactive protein (CRP)

❤️ CRP is a marker of systemic inflammation.

❤️ While it may be elevated in cardiovascular disease, it does not confirm acute myocardial injury.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Place in a prone position.

Rationale :

🌬️ Placing a client with ARDS in the prone position improves oxygenation by enhancing alveolar recruitment and ventilation–perfusion matching.

🌬️ In ARDS, widespread alveolar collapse and inflammation impair gas exchange, leading to severe hypoxemia.

🌬️ Prone positioning redistributes blood flow and reduces shunting, allowing better expansion of posterior lung segments.

🌬️ This intervention has been shown to significantly improve oxygen saturation and decrease mortality in moderate to severe ARDS.

🌬️ It is a critical evidence-based strategy in managing refractory hypoxemia.

Incorrect Options

Offer high-protein and high-carbohydrate foods frequently.

🌬️ Nutrition is important in ARDS management to prevent catabolism.

🌬️ However, airway and oxygenation strategies take priority over dietary interventions.

Encourage oral intake of at least 3,000 mL of fluids per day.

🌬️ Excess fluid intake can worsen pulmonary edema in ARDS.

🌬️ Fluid management is typically conservative to prevent further lung compromise.

Administer low-flow oxygen continuously via nasal cannula.

🌬️ ARDS usually requires high-flow oxygen or mechanical ventilation.

🌬️ Low-flow oxygen via nasal cannula is insufficient for severe hypoxemia.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Breathlessness

Rationale :

❤️ Breathlessness (dyspnea) is a hallmark manifestation of left-sided heart failure due to pulmonary congestion.

❤️ When the left ventricle fails, blood backs up into the pulmonary circulation.

❤️ This increases pulmonary capillary pressure and leads to fluid accumulation in the alveoli.

❤️ The resulting pulmonary edema causes shortness of breath, especially on exertion or lying flat (orthopnea).

❤️ Early recognition of dyspnea allows timely intervention to prevent worsening respiratory compromise.

Incorrect Options

Anorexia

❤️ Anorexia is more commonly associated with right-sided heart failure due to gastrointestinal congestion.

❤️ It is not a primary early sign of left ventricular failure.

Weight gain

❤️ Weight gain may occur due to fluid retention.

❤️ It is more often associated with systemic venous congestion in right-sided failure.

Distended abdomen

❤️ Abdominal distention results from ascites related to right-sided heart failure.

❤️ It is not a typical early manifestation of left-sided failure.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

The client opens his eyes when spoken to.

Rationale :

🧠 A Glasgow Coma Scale eye opening score of 3 indicates eye opening in response to speech.

🧠 The verbal response score of 5 means the client is oriented and converses appropriately.

🧠 The motor response score of 5 indicates the client localizes pain but does not yet follow commands (which would be a score of 6).

🧠 Adding the components together (3 + 5 + 5) gives a total GCS of 13, which reflects mild brain injury rather than unconsciousness.

🧠 Therefore, the most accurate interpretation is that the client opens eyes when spoken to.

Incorrect Options

The client can follow simple motor commands.

🧠 Following commands corresponds to a motor score of 6.

🧠 A motor score of 5 indicates localization of pain, not command-following ability.

The client is unable to make vocal sound.

🧠 A verbal score of 5 reflects normal conversation and orientation.

🧠 Inability to make vocal sounds would be scored as 1.

The client is unconscious.

🧠 A total GCS score of 13 indicates mild impairment.

🧠 Unconsciousness is typically associated with a GCS score of 8 or lower.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Weak pulse

Rationale :

💧 A weak, thready pulse is a classic manifestation of hypovolemia caused by decreased circulating blood volume.

💧 Blood loss reduces preload, stroke volume, and cardiac output.

💧 The body compensates through sympathetic activation, causing tachycardia and peripheral vasoconstriction.

💧 Despite compensation, reduced perfusion results in diminished pulse strength.

💧 Without intervention, persistent volume loss can progress to hypovolemic shock.

Incorrect Options

Dyspnea

💧 Dyspnea is more commonly related to respiratory or cardiac conditions.

💧 It is not a primary early sign of isolated blood volume loss.

Decreased heart rate

💧 Hypovolemia stimulates the sympathetic nervous system.

💧 This results in tachycardia, not bradycardia.

Increased blood pressure

💧 Blood pressure typically decreases as volume loss worsens.

💧 Hypertension is not consistent with hypovolemia.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

2 :
A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care?

Incorrect Options

3 :
A nurse is performing an admission assessment on a client. Which of the following findings should the nurse identify as an indication that the client is dehydrated?

Incorrect Options

4 :
A charge nurse is supervising a newly licensed nurse care for a client who is receiving a transfusion of packed RBC. The nurse suspects a possible
hemolytic reaction. After stopping the blood transfusion, which of the following actions by the new nurse requires intervention by the charge nurse?

Incorrect Options

5 :
A nurse is providing postoperative care to a client who lost 800 mL of blood during surgery. The client's blood pressure has been steadily decreasing over the past 2 hr. Which of the following categories of shock should the nurse recognize is occurring?

Incorrect Options

6 :
A nurse in the emergency department is caring for a client who is experiencing manifestations of a myocardial infarction (MI). Which of the following laboratory tests should the nurse expect the provider to prescribe?

Incorrect Options

7 :
A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?

Incorrect Options

8 :
A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition?

Incorrect Options

9 :
A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

10 :
A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia?

QLexNursing

2 : A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care?

Incorrect Options

3 : A nurse is performing an admission assessment on a client. Which of the following findings should the nurse identify as an indication that the client is dehydrated?

Incorrect Options

4 : A charge nurse is supervising a newly licensed nurse care for a client who is receiving a transfusion of packed RBC. The nurse suspects a possiblehemolytic reaction. After stopping the blood transfusion, which of the following actions by the new nurse requires intervention by the charge nurse?

Incorrect Options

5 : A nurse is providing postoperative care to a client who lost 800 mL of blood during surgery. The client's blood pressure has been steadily decreasing over the past 2 hr. Which of the following categories of shock should the nurse recognize is occurring?

Incorrect Options

6 : A nurse in the emergency department is caring for a client who is experiencing manifestations of a myocardial infarction (MI). Which of the following laboratory tests should the nurse expect the provider to prescribe?

Incorrect Options

7 : A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?

Incorrect Options

8 : A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition?

Incorrect Options

9 : A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

10 : A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia?

2 :
A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care?

3 :
A nurse is performing an admission assessment on a client. Which of the following findings should the nurse identify as an indication that the client is dehydrated?

4 :
A charge nurse is supervising a newly licensed nurse care for a client who is receiving a transfusion of packed RBC. The nurse suspects a possible
hemolytic reaction. After stopping the blood transfusion, which of the following actions by the new nurse requires intervention by the charge nurse?

5 :
A nurse is providing postoperative care to a client who lost 800 mL of blood during surgery. The client's blood pressure has been steadily decreasing over the past 2 hr. Which of the following categories of shock should the nurse recognize is occurring?

6 :
A nurse in the emergency department is caring for a client who is experiencing manifestations of a myocardial infarction (MI). Which of the following laboratory tests should the nurse expect the provider to prescribe?

7 :
A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?

8 :
A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition?

9 :
A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

10 :
A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia?