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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Correct Answer is C

Explanation

A) Tricuspid and mitral: The tricuspid and mitral valves are best auscultated over the areas where the heart's valves are closest to the chest wall, specifically at the lower left sternal border and the apex, respectively. A louder S2 in the 2nd intercostal space right sternal border does not indicate the closure of these valves.
B) Mitral and aortic: The mitral valve is auscultated at the apex, and the aortic valve is best heard at the 2nd intercostal space right sternal border. While a louder S2 may be associated with the aortic valve, it is not consistent with the mitral valve.
C) Aortic and pulmonic: The aortic valve and pulmonic valve are located in the areas where S2 (second heart sound) is predominantly heard. The aortic valve is located at the 2nd intercostal space right sternal border, and the pulmonic valve is heard at the 2nd intercostal space left sternal border. A louder S2 in the 2nd intercostal space right sternal border indicates a louder closure of the aortic valve and potentially the pulmonic valve as well.
D) Pulmonic and tricuspid: The pulmonic valve is auscultated at the 2nd intercostal space left sternal border, while the tricuspid valve is heard best at the lower left sternal border. A louder S2 in the 2nd intercostal space right sternal border does not indicate the closure of the tricuspid valve.

A. Instruct the patient on Tripod positioning B. Restrict the client's fluid intake to less than 2 U/day. C. Provide the client with a low-protein diet. D. Have the client use the early-morning hours for exercise and activity.

Correct Answer is A

Explanation

A) Instruct the patient on Tripod positioning: Tripod positioning, where the patient leans forward with hands on their knees or a table, is beneficial for COPD patients. It helps improve ventilation by allowing the diaphragm to work more efficiently and aiding in the expansion of the lungs. This position also utilizes accessory muscles, which can help ease breathing and reduce the work of respiration.
B) Restrict the client's fluid intake to less than 2 L/day: Restricting fluid intake is generally not advisable for COPD patients unless there is a specific condition such as severe heart failure where fluid restriction is necessary. Adequate fluid intake helps to thin mucus, making it easier to expectorate and thus supports better lung function and overall respiratory health.
C) Provide the client with a low-protein diet: COPD patients typically require a higher-protein diet to maintain muscle mass and strength, which are crucial for overall health and respiratory function. A low-protein diet can lead to muscle wasting, including the respiratory muscles, which can worsen respiratory symptoms and functional status.
D) Have the client use the early-morning hours for exercise and activity: While regular exercise is important, the timing should be based on the client's individual preferences and tolerance. For some patients, early morning might not be the best time due to morning symptoms or fatigue. The exercise plan should be customized to fit the patient’s daily routine and energy levels.

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Naxlex Comprehensive Predictor Exams

When auscultating a client's heart sounds, the nurse hears a louder S2 when listening at the 2nd intercostal space right sternal border. The nurse determines that this finding is consistent with the closure of which heart valves?

Correct Answer is C

Explanation

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?

Correct Answer is A

Explanation

The nurse suspects an older adult client has congestive heart failure. Which of the following did the nurse most likely assess in the client?

Which strategy can the nurse use to effectively approach the older adult client during the health history?

A 16-year-old female client presents with complaints of palpitations. While the nurse is auscultating heart sounds, asking the client to get into a seated position and leaning forward, would help the nurse assess the presence of which of the following?

The nurse assesses a client who reports chronic pain with chewing. The nurse should assess which body area to investigate the client's problem further?

When assessing an adult client experiencing diarrhea, the nurse notes a round "moon" face, a buffalo hump at the nape of the neck, and a velvety discoloration around the neck. What is the possible cause of these signs?

A patient is diagnosed with a Pneumothorax on the right lung. During the assessment, when percussing this area the nurse expects to find the percussion note as:

A 54 year-old client diagnosed with Bipolar disorder is clenching his jaw closed to avoid taking a prescribed oral medication. The nurse can use this observation to confirm the client is demonstrating motor function of which cranial nerve?

While performing an assessment the nurse presses the client's arm with the tip of her thumb, holds for a few seconds and releases. The nurse observes the client as shown. What is the nurse assessing?