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.

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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.

A. Cover the wound with a sterile normal saline soaked dressing. B. Apply an abdominal binder to the wound area. C. Assure the client that this is an expected occurrence after surgery. D. Turn the client onto her side.

Correct Answer is A

Explanation

A. Cover the wound with a sterile normal saline soaked dressing:
This keeps the exposed organs moist and reduces infection risk until surgical intervention.

B. Apply an abdominal binder to the wound area:
This can increase pressure and cause further damage to exposed organs.

C. Assure the client that this is an expected occurrence after surgery:
Evisceration is a surgical emergency, not expected.

D. Turn the client onto her side:
The client should be placed in a low Fowler’s position with knees bent to reduce abdominal strain-not on the side.

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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 a stage 1 pressure injury. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is caring for a client whose surgical abdominal wound has eviscerated. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who has a rectal temperature of 35° C (95° F). Which of the following actions should the nurse take?

A nurse is assisting with obtaining an aerobic wound culture for a client. Which of the following actions should the nurse recommend taking first?

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 caring for a client who has a stage-3 pressure ulcer that now has some granulating tissue. Which of the following interventions should the nurse recommend for inclusion in the plan of care?

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?

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?

A patient is obese. At the bedside is a standard-size blood pressure cuff. The nurse realizes that the use of this cuff will provide which of the following?

Which of the following interventions is important for preventing dehiscence of an abdominal incision?

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.