A nurse is assisting with the care of a client.
Temperature
Pulse oximetry
Respiratory rate
Blood pressure
Mucous membrane color
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Cleanse the wound with sterile saline:
This removes surface contaminants, ensuring the specimen reflects organisms within the wound, not contaminants from the skin.
B. Don sterile gloves:
While sterile technique is important, cleansing the wound must occur before donning sterile gloves to prevent contaminating the site.
C. Swab the wound bed with a sterile cotton-tipped swab:
This is done after cleansing the wound to collect an accurate sample.
D. Place the collection tube in a specimen bag:
This is the final step after the specimen is collected.
Correct Answer is B
Explanation
A. Partial-thickness skin loss with red tissue in wound bed:
This describes a stage 2 pressure injury, not stage 1.
B. Intact skin with localized erythema:
Stage 1 pressure injuries are characterized by non-blanchable redness (erythema) over intact skin.
C. Full thickness skin loss with visible adipose tissue:
This describes a stage 3 pressure injury.
D. Full thickness skin loss with visible bone:
This describes a stage 4 pressure injury.
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