Client data

Complete the table by matching each client data to the appropriate goal of care

Surgical dressing dry and intact

PaCO2 42 mm Hg

Pain 0 on a scale of 0 to 10

Blood pressure 112/77 mm Hg

Capillary refill 2 seconds

Temperature 98.1° F (36.7°C)

pH 7.40

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"D"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"B"},"G":{"answers":"A"}}

Support Ventilation:

PaCO₂ 42 mm Hg: This value falls within the normal range of 35–45 mm Hg, indicating adequate ventilation and effective CO₂ removal. It supports that the client's ventilator settings are maintaining proper respiratory function.
pH 7.40: A normal arterial blood pH indicates stable acid-base status, suggesting that respiratory and metabolic functions are balanced. This reflects effective ventilatory support and tissue perfusion.

Prevent Infection:

Surgical dressing dry and intact: A dry, intact dressing helps maintain a sterile barrier over the surgical site, reducing the risk of contamination. It indicates no active bleeding or signs of surgical wound infection.
Temperature 98.1°F: A normothermic reading helps support immune function and prevent infection. In trauma care, avoiding hypothermia is also important in preventing coagulopathy and sepsis.

Manage Hypovolemia:

Blood pressure 112/77 mm Hg: This blood pressure is within a normal range, showing stable perfusion and likely adequate volume status after earlier hypotension. It indicates a positive response to fluid management.
Capillary refill 2 seconds: A refill time under 2–3 seconds indicates good peripheral perfusion and supports adequate intravascular volume. It is a quick, non-invasive indicator of circulatory status.

Control Pain and Anxiety:

Pain 0 on a scale of 0 to 10: A pain score of 0 indicates successful pain control, which helps prevent agitation, reduces metabolic demand, and supports healing. Adequate pain management also minimizes stress response.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Maintain elevated positioning of the dependent joints on affected side: Elevating joints can help reduce edema but is not the priority during the acute phase of a suspected stroke where airway, breathing, and circulation must be prioritized.

B. Initiate bilateral intermittent sequential pneumatic compression devices: Preventing deep vein thrombosis is important in immobile patients, but it is not the immediate intervention needed for stabilizing a client with acute neurological changes.

C. Obtain a focused history to determine recent bleeding and use of anticoagulants: Gathering information on bleeding risk is necessary before administering thrombolytics but is secondary to immediately stabilizing the client’s airway and cerebral perfusion.

D. Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment: Elevating the head helps decrease intracranial pressure, improves cerebral venous drainage, and reduces aspiration risk, which are critical priorities in the immediate management of suspected stroke.

A. Mark the chart with client's request for no heroic measures. B. Reassure the client that the client's child will be allowed to visit. C. Provide the client written information about end-of-life care. D. Obtain a detailed report from the nurse transferring the client.

Correct Answer is D

Explanation

A. Mark the chart with client's request for no heroic measures: While it's essential to document the client's advance directives, this task is administrative and should occur after a complete clinical handoff. It does not, by itself, ensure continuity of comprehensive care.

B. Reassure the client that the client's child will be allowed to visit: Emotional support is important, but logistical or emotional reassurance without fully understanding the client's current condition, preferences, and care needs may miss critical aspects of transitional care.

C. Provide the client written information about end-of-life care: Offering educational material is helpful but not a priority at the time of transfer. The nurse first needs a clear clinical picture and context to provide care tailored to the client's stage, goals, and comfort.

D. Obtain a detailed report from the nurse transferring the client: A thorough handoff ensures the receiving nurse understands the client’s medical history, current condition, treatment preferences, and psychosocial needs. This is foundational for safe, personalized, and continuous palliative care.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Client data Complete the table by matching each client data to the appropriate goal of care

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)

Correct Answer is D

Explanation

Correct Answer is D

Explanation

During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

The nurse assesses a client who had bilateral total knee replacements (TKR) four hours ago. The nurse notes that the dressing on the client's right knee is saturated with serosanguineous drainage. Which action should the nurse implement?

Exhibits select from Word Choices to complete the sentence. The client receiving epidural anesthesia would be at risk for developing dropdown due to dropdown

The school nurse is preparing a teaching pamphlet in response to requests from parents regarding an outbreak of pinworms at the local preschool. Which information about the most commonly prescribed medication, mebendazole, should be included?

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

While caring for a toddler receiving oxygen via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?

Client data

Complete the table by matching each client data to the appropriate goal of care