A nurse is assisting with the care of a client
Pedal pulses
Heart rate
Oxygen saturation
Blood pressure
Abdominal dressing
Breath sounds
Correct Answer : B,D,E
Rationale:
• Heart rate of 110/min indicates tachycardia, which can be an early sign of hypovolemia, sepsis, or pain and should be followed up due to the recent report of a "popping" sound and increased drainage.
• Abdominal dressing now has a large amount of serosanguinous drainage, suggesting possible wound dehiscence or evisceration, which is a surgical emergency requiring prompt evaluation.
• Blood pressure of 98/50 mm Hg indicates hypotension, which, along with tachycardia and fever, suggests potential sepsis or internal fluid loss and needs immediate intervention.
• Pedal pulses are 2+, which is within normal limits and unchanged from Day 1, indicating adequate peripheral perfusion at present.
• Oxygen saturation at 95% on room air is within normal limits and not significantly changed from previous levels, requiring no urgent action.
• Breath sounds are still clear and present bilaterally, indicating no respiratory compromise or pulmonary complication at this time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Notify the unit manager: Informing the unit manager is necessary for institutional follow-up and quality assurance. However, it is not the immediate concern. Client safety and clinical status must be assessed first to determine if harm has occurred due to the error.
B. Collect data on the client: Assessing the client is the priority to determine if the excessive fluid has caused complications such as fluid overload, pulmonary edema, or changes in vital signs. Early identification of adverse effects is essential to guide further intervention.
C. Notify the provider: The provider should be informed after assessing the client so that appropriate medical interventions or monitoring can be initiated. Immediate data collection ensures the nurse can give accurate information about the client’s status.
D. Complete an incident report: Documentation of the error is an important step for institutional learning and accountability. However, it is not time-sensitive in the way client safety and assessment are and should follow after urgent clinical actions are taken.
Correct Answer is B
Explanation
Rationale:
A. "I will follow a full-liquid diet the day before the procedure.": Clients are typically instructed to follow a clear-liquid, not full-liquid, diet the day before a colonoscopy. Clear liquids like broth, gelatin, and clear juice help ensure the colon is clean for optimal visualization.
B. "I'll have my friend drive me home after the procedure.": Sedation is usually administered during a colonoscopy, which impairs alertness and coordination. Having a responsible adult to drive the client home is necessary and reflects appropriate understanding of post-procedure safety.
C. "I can expect rectal bleeding for a week after the procedure”: Rectal bleeding after a colonoscopy is not expected and could indicate complications such as a perforation or polyp removal site bleeding. Any persistent or heavy bleeding should be reported immediately.
D. "This procedure will take place while I’m under general anesthesia.”: Colonoscopies are generally performed under moderate (conscious) sedation, not general anesthesia. Clients remain semi-awake but relaxed and unaware, making this statement inaccurate.
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