A nurse is caring for a 24-year-old female client in the post-operative unit following a horseback riding accident.
Oxygen saturation of 100% on 40% oxygen
Capillary refill time of 6 seconds
Blood pressure of 90/79 mmHg with a pulse pressure of less than 40 mmHg
The client’s lack of urine output from the indwelling catheter
Correct Answer : B,C,D
Choice B rationale: Capillary refill time of 6 seconds is significantly delayed and indicates poor peripheral perfusion. This finding suggests that the client may be experiencing decreased cardiac output or hypovolemia, which requires immediate attention to improve circulation and oxygen delivery to tissues.
Choice C rationale: Blood pressure of 90/79 mmHg with a pulse pressure of less than 40 mmHg is a critical finding. The narrow pulse pressure and hypotension indicate potential hypovolemia or shock, which must be addressed urgently to stabilize the client's hemodynamic status.
Choice D rationale: The client’s lack of urine output from the indwelling catheter is concerning and indicates potential kidney dysfunction or decreased renal perfusion. Immediate intervention is necessary to assess and manage potential underlying causes, such as hypovolemia or renal injury.
Choice A rationale: Oxygen saturation of 100% on 40% oxygen is not an immediate concern. While it is important to continue monitoring oxygen levels, the client is currently receiving adequate oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
An older client one day postoperative with a colostomy for colon cancer may have complex needs that require the expertise of an RN rather than a PN.
Choice B rationale
An older adult scheduled for foot amputation due to diabetes complications may also have complex needs and potential complications that necessitate the supervision of an RN.
Choice C rationale
An adult with alcoholism, cirrhosis, and hepatic encephalopathy is likely to have complex medical issues and require close monitoring and interventions, best suited for an RN.
Choice D rationale
An adult one day postoperative for a laparoscopic cholecystectomy is generally stable and has less complex needs, making them an appropriate assignment for a PN.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
Rationale for correct answers
Neglect: The client’s condition and living situation indicate neglect. The client is frail, has poor hygiene, unkempt hair, dry skin, and visible pressure injuries. The daughter, who is the primary caregiver, admits to being overwhelmed and neglecting the client’s needs, such as hygiene and repositioning. Neglect is defined as the failure to provide necessary care, assistance, and supervision to a dependent individual, leading to harm or potential harm.
Adult Protective Services: As a mandated reporter, the nurse must report the signs of elder mistreatment to Adult Protective Services (APS). APS is responsible for investigating reports of abuse, neglect, and exploitation of elderly or disabled adults. Reporting to APS ensures that the client receives the necessary intervention and support to address the neglect and improve her quality of life.
Rationale for incorrect answers
Abandonment: Abandonment refers to deserting an elderly person, leaving them without the necessary care and support. In this case, the client has not been deserted; her daughter is present and attempting to provide care, although she is overwhelmed and neglectful. Therefore, abandonment is not the correct answer.
Physical abuse: Physical abuse involves the intentional use of physical force that results in bodily injury, pain, or impairment. There is no evidence of physical abuse in this case. The client’s condition is due to neglect, not physical harm inflicted by another person.
Self-neglect: Self-neglect occurs when an individual fails to meet their own basic needs, such as personal hygiene, nutrition, or medical care. In this scenario, the client is dependent on her daughter for care and unable to provide for herself due to limited mobility. The neglect is not self-imposed but rather due to the caregiver's inability to meet her needs.
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