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 D

Explanation

A. Flatness: This percussion note is typically associated with areas of high density, such as over muscle or a solid organ like the liver. In a pneumothorax, the lung tissue is not solidified, so flatness is not expected.
B. Dullness: Dullness is generally noted over fluid-filled areas or solid structures, such as a pleural effusion or a mass. In the case of a pneumothorax, where there is air in the pleural space, dullness would not be the expected finding.
C. Resonance: Resonance is the normal percussion note over healthy lung tissue. It indicates normal air-filled lung spaces. In a pneumothorax, the increased air in the pleural space causes an abnormal note.
D. Hyperresonance: This percussion note is associated with increased air in the pleural space, as seen in conditions like a pneumothorax. The extra air causes a more resonant, hollow sound when percussed, distinguishing it from normal lung resonance.

A. Wear socks when walking around the home. B. Install grab bars in the bathtub. C. Secure rugs with adhesive tape. D. Use nightlights along stairways and walkways. E. Install handrails on both sides of all stairways.

Correct Answer is ["B","C","D","E"]

Explanation

A) Wear socks when walking around the home: Wearing socks, especially if they have smooth soles, can increase the risk of slipping on hard surfaces. Non-slip footwear is recommended for preventing falls. Therefore, recommending socks for walking may not address the safety concerns effectively.
B) Install grab bars in the bathtub: Installing grab bars in the bathtub is a crucial safety measure for preventing falls and providing support for older adults while bathing. This helps reduce the risk of slips and injuries in a common high-risk area for falls.
C) Secure rugs with adhesive tape: Securing rugs with adhesive tape helps prevent them from slipping, which can significantly reduce the risk of tripping and falling. Loose or unsecured rugs are common hazards in the home environment.
D) Use nightlights along stairways and walkways: Using nightlights along stairways and walkways improves visibility and helps prevent falls during the night. Adequate lighting is essential for older adults to navigate their homes safely.
E) Install handrails on both sides of all stairways: Installing handrails on both sides of stairways provides additional support and stability, which is particularly important for older adults to prevent falls while using stairs. This enhancement helps ensure safer navigation of stairs.

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Naxlex Comprehensive Predictor Exams

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:

Correct Answer is D

Explanation

Which of the following should the nurse include in her teaching plan to address home safety for an older adult client? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

The right 2nd rib space is the first location for cardiac auscultation and is also known as:

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?

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?

When preparing to test a client for meningeal irritation, which of the following would be most important for the nurse to do first?

A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. Which is an "ABCD" characteristic of malignant melanoma?

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?

Which cranial nerves are involved in eye movements? Select all that apply.

The nurse reads in the patient chart the doctor's day round note. The doctor writes AOX3, the nurse knows this means the patient is oriented to: Select all that apply.