A nurse is assisting with the care of a client.

Exhibits
For each finding at 1100, click to specify if the finding indicates that the client's condition has improved, worsened, or is unchanged.

Temperature

Pulse oximetry

Respiratory rate

Blood pressure

Mucous membrane color

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}

Finding	Assessment	Rationale
Temperature: 38.6°C	Worsened	The temperature increased from 38.2°C to 38.6°C, suggesting worsening fever or infection.
Pulse oximetry: 95% on 40% O₂	Improved	The client’s oxygen saturation increased from 85% to 95%, though with supplemental O₂, showing improved oxygenation.
Respiratory rate: 22/min	Improved	RR decreased from 32 to 22, indicating better respiratory effort and less distress.
Blood pressure: 112/54 mmHg	Unchanged	Minimal change from 114/56 to 112/54; both readings are within similar ranges.
Mucous membrane color: pink	Improved	Pink mucous membranes indicate improved oxygenation and perfusion, compared to pale earlier.

Nursing Test Bank

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Correct Answer is C

Explanation

A. Decreased serum calcium:
Low calcium affects bones and muscle contraction but is not directly related to pressure injury development.

B. Increased muscle mass:
Increased muscle mass helps protect against pressure injury by providing padding and blood flow.

C. Decreased circulation:
Poor circulation leads to inadequate oxygen and nutrient delivery to tissues, increasing the risk of pressure injury, especially in immobile clients.

D. Increased collagen:
Collagen is essential for skin integrity and wound healing. Increased collagen would protect, not harm, tissue.

A. Replace the drainage plug after releasing hand pressure on the device. B. Empty the reservoir once per day. C. Fully recollapse the reservoir after emptying it. D. Irrigate the tubing with sterile normal saline solution at least once every 8 hr.

Correct Answer is C

Explanation

A. Replace the drainage plug after releasing hand pressure on the device:
Doing this allows air into the reservoir, preventing the vacuum effect. Plug should be replaced while still compressed.

B. Empty the reservoir once per day:
Reservoirs should be emptied at least every shift or when half full, not just once a day.

C. Fully recollapse the reservoir after emptying it:
This restores negative pressure, allowing continuous drainage and wound healing.

D. Irrigate the tubing with sterile normal saline solution at least once every 8 hr:
Irrigating the tubing is not standard care for closed-wound drains and can introduce infection.

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A nurse is assisting with the care of a client. Exhibits For each finding at 1100, click to specify if the finding indicates that the client's condition has improved, worsened, or is unchanged.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors?

Correct Answer is C

Explanation

A nurse is assisting with the care of a client who is postoperative and has a closed-wound drainage system in place. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse palpates a client's radial pulses bilaterally and notes the client's right radial pulse is bounding, and the client's left radial pulse is as expected. The client's heart rate is 80/min. Which of the following documentations should the nurse make?

A nurse is assisting with teaching a class about documenting blood pressure. The nurse should include to document which of the following information?

A nurse is preparing to obtain an electronic blood pressure measurement on a client. Which of the following actions should the nurse plan to take?

A nurse is reviewing blood pressure classifications with a client who has been newly diagnosed with hypertension. Which of the following should the nurse include as an example of stage 1 hypertension?

A nurse is preparing to measure a client's oral temperature. The client states that he has just had some ice chips in his mouth. Which of the following actions should the nurse take?

A nurse is collecting data on a client who has a wound that is healing by first intention. Which of the following findings should the nurse expect?

A nurse is caring for a client who has a Penrose drain. Which of the following actions should the nurse take?

A nurse is assisting in the care of a client. Exhibits Click to highlight the findings that indicate the interventions were effective. To deselect a finding, click on the finding again. T 38° C (100.4)°F, oral. BP 106/60 mm Hg, supine HR 99/min R 20/min Pulse oximetry 95% on room air

A nurse is assisting with the care of a client.

Exhibits
For each finding at 1100, click to specify if the finding indicates that the client's condition has improved, worsened, or is unchanged.