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 A
Explanation
Choice A rationale
Asking the client to describe the pain is the most effective way to assess the quality of pain. This approach allows the client to provide specific details about their pain experience, including the type, intensity, and characteristics, which are essential for accurate pain management.
Choice B rationale
Identifying effective pain relief measures is important but does not directly assess the quality of pain. This step is more focused on treatment rather than the initial assessment of pain quality.
Choice C rationale
Observing body language and movement can provide additional information about the pain but is not as reliable as directly asking the client. Nonverbal cues should supplement, not replace, the client's verbal report.
Choice D rationale
Providing a numeric pain scale helps quantify the intensity of pain but does not assess the quality. Quality assessment requires a descriptive approach to understand the nature of the pain fully.
Correct Answer is B
Explanation
Choice A rationale
Explaining that every client will receive the same high level of care does not address the client's specific concerns about receiving care in accordance with their religion. It is important to recognize and respect individual preferences and beliefs in healthcare.
Choice B rationale
Asking the client about individual care preferences is the best action as it allows the nurse to understand and accommodate the client's specific religious needs and preferences. This approach demonstrates respect for the client's beliefs and promotes patient-centered care.
Choice C rationale
Consulting with a nurse who shares the same religious beliefs might provide some insight, but it is not the best approach. The client may have unique personal preferences that differ from general practices of their religion, so direct communication with the client is more effective.
Choice D rationale
Researching the religion on social media platforms is not a reliable or appropriate way to gather information about a client's care preferences. Social media may not provide accurate or comprehensive information, and personal preferences should be discussed directly with the client. .
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