A nurse performs a head-to-toe assessment on a newly admitted client. Data analysis reveals temperature 100.94°F (38.3°C), blood pressure 82/58 mm Hg, 02 saturation 95% on room air, productive cough, lethargy, diaphoresis, WBC 15,000 mm3, hemoglobin 9 g/dl, and hematocrit 29%. Based on the analysis of the data, which of the following client concerns is a priority?

hypoxia

anemia

hypotension

Pneumonia

Answer and Explanation

The Correct Answer is C

A) Hypoxia: Although the client's oxygen saturation is slightly decreased at 95% on room air, it is not critically low. Hypoxia could be a concern, but it is secondary to other more immediate issues, such as hypotension, that might be causing the low oxygen saturation.
B) Anemia: The client’s hemoglobin and hematocrit levels are low, indicating anemia. While anemia is a significant concern, it does not pose an immediate threat compared to hypotension, which can lead to more severe complications if not addressed promptly.
C) Hypotension: The client’s blood pressure is notably low at 82/58 mm Hg. Hypotension can lead to inadequate perfusion of vital organs and may be a result of or contribute to other issues such as sepsis or significant blood loss. Immediate attention to correcting hypotension is crucial to prevent further complications.
D) Pneumonia: The client presents with symptoms suggestive of pneumonia, including a productive cough, fever, and elevated white blood cell count. While pneumonia is a critical condition that requires treatment, addressing hypotension is a more urgent priority as it directly impacts the client's circulatory stability and overall well-being.

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Free Nursing Study Resources

Correct Answer is "{\"xRanges\":[104.828125,113.828125],\"yRanges\":[122.5,131.5]}"

Explanation

To auscultate the apical pulse, the nurse should place the stethoscope at the fifth intercostal space, midclavicular line on the left side of the chest. This location is where the apex of the heart is closest to the chest wall, making it the best spot for assessing the apical pulse.

Correct Answer is "{\"xRanges\":[null,null],\"yRanges\":[null,null]}"

Explanation

Answer: The hot spot in the right lower quadrant that corresponds to this location.

Locate the right anterior superior iliac spine (the bony prominence on the right side of the pelvis). Identify the umbilicus (navel). McBurney's point is roughly one-third of the distance from the anterior superior iliac spine to the umbilicus.

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Naxlex Comprehensive Predictor Exams

A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's apical pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Correct Answer is "{\"xRanges\":[104.828125,113.828125],\"yRanges\":[122.5,131.5]}"

Explanation

A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point. (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

Correct Answer is "{\"xRanges\":[null,null],\"yRanges\":[null,null]}"

Explanation

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