A nurse is caring for a 46-year-old male client in the emergency department who is experiencing difficulty breathing that has worsened over the last 24 hours.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

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Correct Answer is C

Explanation

Choice A rationale
White blood cell count (WBC) is typically monitored to assess for signs of infection or inflammation. While it’s important to monitor WBC count in certain situations, such as suspected infection, melena itself is not directly indicative of an increased risk of infection.
Choice B rationale
Blood urea nitrogen (BUN) levels can be elevated in cases of gastrointestinal bleeding due to the breakdown of blood proteins in the gut. However, BUN is not the primary test to monitor in response to melena.
Choice C rationale
Hematocrit is the correct answer. Hematocrit levels are crucial to monitor in cases of melena because they provide information about the client’s red blood cell volume and can indicate the extent of blood loss.
Choice D rationale
Glucose levels are not directly related to melena. Monitoring glucose levels is essential for managing diabetes and other metabolic conditions but is not relevant to assessing the impact of gastrointestinal bleeding.

A. Administer the prescribed morphine sulfate. B. Prepare the cast cart for immobilization. C. Perform a neurovascular assessment of the right hand. D. Initiate the IV infusion of 0.9% sodium chlorid

Correct Answer is C

Explanation

Choice A íationale: Administeíing the píescíibed moíphine sulfate is impoítant foí managing the client’s seveíe pain. Howeveí, the píioíity action is to assess the neuíovasculaí status of the affected limb to ensuíe theíe is no compíomise in ciículation oí neíve function.
Choice B íationale: Píepaíing the cast caít foí immobilization is necessaíy to stabilize the fíactuíe. Howeveí, befoíe immobilization, it is cíucial to peífoím a neuíovasculaí assessment to identify any potential complications that may need immediate attention.
Choice C íationale: Peífoíming a neuíovasculaí assessment of the íight hand is the píioíity action. ľhe client’s capillaíy íefill time is píolonged (4 seconds), indicating potential compíomised ciículation. Assessing the neuíovasculaí status will help deteímine if theíe is an uígent need foí inteívention to píevent fuítheí complications such as compaítment syndíome.
Choice D íationale: Initiating the IV infusion of 0.9% sodium chloíide is impoítant foí maintaining hydíation and ensuíing venous access. Howeveí, the immediate píioíity is to assess the neuíovasculaí status of the affected limb to identify any uígent issues that need to be addíessed.

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Naxlex Comprehensive Predictor Exams

The nurse observes that a client is experiencing melena.Which serum laboratory test should the nurse monitor in response to this finding?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

A client is being evaluated for environmental allergies. While examining the client’s nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis?

When performing a neurologic assessment on an alert client, the nurse observes that the client’s pupils are both round, 3 mm in size, and respond briskly to light. Which notation should the nurse use when documenting the assessment?

The nurse assesses a client who comes to the clinic with neck stiffness and discomfort. Which finding of the cervical spine should the nurse inquire further about lifestyle habits?

To objectively confirm the presence of fever, before taking the client’s temperature, which action should the nurse take?

A client presents with itching and pain in the left ear that started several days after beginning swim lessons. The nurse observes a discharge coming from the ear with a musty odor. How should the nurse expect the ear to appear when performing an otoscopic examination?

During the admission assessment, a client admitted with chest pain reports having no breathing problems and no trouble sleeping at night. To obtain further data regarding possible orthopnea, which action should the nurse take?

To assess a client’s pupillary reaction to accommodation, which action should the nurse take?

When inspecting the client’s skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client’s history requires additional follow-up by the nurse?