An intubated 30-year-old is being treated in the critical care unit after coming into contact with a high voltage power line. The client’s left leg received a compound fracture as well as a full thickness circular burn. Three days post-injury a fasciotomy was performed. Which assessment findings indicate effectiveness of the actions taken by the nurse? (Select all that apply)

Pedal pulse 88 beats/min, bilaterally.

No swelling noted in lower extremities.

Spontaneous respirations, 16 breaths/minute.

Pulse oximeter reading 93%.

Pain scored 5 out of 10, decreased from high of 10.

Temperature 98.6°F.

Answer and Explanation

Correct Answer : A,B,E

Choice A reason: Bilateral pedal pulses at 88 beats/min indicate restored circulation post-fasciotomy, preventing compartment syndrome. This aligns with vascular assessment post-burn and fracture, making it a correct finding showing the nurse’s actions were effective in maintaining perfusion in the leg.

Choice B reason: No swelling in lower extremities post-fasciotomy indicates reduced pressure and effective decompression, preventing tissue damage. This aligns with post-surgical burn care, making it a correct finding demonstrating the nurse’s actions were successful in managing the client’s leg injury.

Choice C reason: Spontaneous respirations are expected with intubation but unrelated to fasciotomy effectiveness for leg burn and fracture. Pulse presence is more relevant, making this incorrect, as it does not reflect the outcome of the nurse’s actions on the leg injury.

Choice D reason: Pulse oximetry of 93% reflects respiratory status, not fasciotomy effectiveness for leg perfusion. No swelling is a direct outcome, making this incorrect, as it’s unrelated to the nurse’s actions addressing the burn and fracture in the client’s leg.

Choice E reason: Pain reduced to 5/10 from 10 post-fasciotomy indicates effective decompression and pain management. This aligns with post-surgical burn care outcomes, making it a correct finding showing the nurse’s actions improved the client’s comfort and leg injury status.

Choice F reason: Normal temperature of 98.6°F is expected but doesn’t directly indicate fasciotomy effectiveness for leg perfusion. Pedal pulses are more specific, making this incorrect, as it’s not a primary outcome of the nurse’s actions for the client’s leg injury.

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Correct Answer is ["A","B","E","G","I"]

Explanation

Choice A reason: Decreased cardiac output is a hallmark of cardiogenic shock, as the heart fails to pump adequately. This aligns with shock pathophysiology, making it a correct manifestation the nurse would expect when assessing a client for cardiogenic shock in a clinical setting.

Choice B reason: Increased pulse rate occurs in cardiogenic shock as the body compensates for low cardiac output. This aligns with cardiovascular assessment findings, making it a correct manifestation the nurse would identify in a client experiencing cardiogenic shock during evaluation.

Choice C reason: Postural hypotension is more typical of hypovolemic or orthostatic issues, not cardiogenic shock, which features weak pulses. Weak thready pulse is correct, making this incorrect, as it’s not a primary sign of cardiogenic shock in the nurse’s assessment.

Choice D reason: Bounding pulse suggests hyperdynamic circulation, not cardiogenic shock, where perfusion is poor. Weak thready pulse is typical, making this incorrect, as it does not reflect the compromised cardiac output expected in the nurse’s evaluation of cardiogenic shock.

Choice E reason: Weak thready pulse indicates poor perfusion in cardiogenic shock due to reduced cardiac output. This aligns with peripheral vascular assessment, making it a correct manifestation the nurse would expect when assessing a client in cardiogenic shock.

Choice F reason: Hypertension is not typical in cardiogenic shock, which often presents with hypotension due to pump failure. Pink frothy sputum is correct, making this incorrect, as it contradicts the hemodynamic profile in the nurse’s assessment of cardiogenic shock.

Choice G reason: Capillary refill greater than 3 seconds reflects poor perfusion in cardiogenic shock, consistent with low cardiac output. This aligns with peripheral assessment findings, making it a correct manifestation the nurse would note in a client with cardiogenic shock.

Choice H reason: Capillary refill less than 3 seconds suggests normal perfusion, not cardiogenic shock, where refill is delayed. Greater than 3 seconds is correct, making this incorrect, as it does not align with the poor perfusion in cardiogenic shock assessment.

Choice I reason: Pink frothy sputum indicates pulmonary edema, common in cardiogenic shock due to left heart failure. This aligns with respiratory assessment findings, making it a correct manifestation the nurse would expect in a client with cardiogenic shock.

A. Hypertension, tachycardia, and fever. B. Hypotension, bradycardia, and hypothermia. C. Restlessness, irritability, and generalized weakness. D. Headache, deteriorating level of consciousness, and twitching.

Correct Answer is D

Explanation

Choice A reason: Hypertension and tachycardia may occur in dialysis but aren’t specific to disequilibrium syndrome, which causes neurological symptoms. Headache and twitching are key, making this incorrect, as it’s less precise than the nurse’s expected manifestations of disequilibrium syndrome.

Choice B reason: Hypotension may occur in dialysis, but bradycardia and hypothermia aren’t typical of disequilibrium syndrome, which affects the brain. Deteriorating consciousness is correct, making this incorrect, as it doesn’t align with the nurse’s assessment for this complication.

Choice C reason: Restlessness and weakness are vague and less specific than headache and twitching, which indicate cerebral edema in disequilibrium syndrome. This is incorrect, as it’s not the primary manifestation the nurse would assess in the dialysis client.

Choice D reason: Headache, deteriorating consciousness, and twitching indicate disequilibrium syndrome due to rapid osmotic shifts during hemodialysis. This aligns with neurological assessment, making it the correct set of manifestations the nurse would monitor in the client at risk.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client. Which of the following manifestations would indicate that the client is in cardiogenic shock? (Select all that apply)

Correct Answer is ["A","B","E","G","I"]

Explanation

The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse would assess the client during dialysis for which associated manifestations?

Correct Answer is D

Explanation

The nurse is providing dietary education to a client with gastroesophageal reflux disease (GERD). The nurse indicates that the client understands the teaching if the client states a plan to avoid which foods to prevent symptom exacerbation? (Select all that apply)

A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. The nurse would anticipate a prescription from the primary health care provider for which type of diet for this client?

The nurse provides instructions to a client about measures to treat irritable bowel syndrome (IBS). Which statement by the client indicates a need for further teaching?

Which action will the nurse perform first to prevent harm for a client suspected to have fluid overload?

A patient with acute lung failure has been on a ventilator for 3 days and is being considered for weaning. When entering the room, the ventilator inoperative alarm sounds. What action should the nurse take FIRST?

The nurse cares for a client in the emergency department diagnosed with deep partial thickness burns of the arms and chest. The nurse notes that the client is very restless and anxious. Which action should the nurse take FIRST?

The primary health care provider has determined that a client has contracted hepatitis A based on flu-like symptoms and jaundice. Which statement made by the client supports this medical diagnosis?