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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

• Appendicitis: The sudden onset of right lower quadrant pain, elevated WBC count, low-grade fever, and CT scan findings of a dilated appendix and fat stranding point to acute appendicitis. This is a common surgical emergency that requires prompt diagnosis and intervention.

• Computed tomography (CT) scan results: The CT scan is the most definitive diagnostic tool for appendicitis. A 7 mm dilated appendix with fat stranding is classic radiologic evidence of appendiceal inflammation and supports surgical consultation.

• White blood cell count: The client’s WBC is 16,000/mm³, which is elevated and indicative of a systemic inflammatory response, commonly seen in appendicitis. Leukocytosis helps confirm infection and supports imaging findings.

Rationale for Incorrect Options:

• Gastroenteritis: Typically presents with diffuse abdominal cramping, diarrhea, and vomiting, often related to foodborne illness or viral infection. The absence of diarrhea and the presence of localized RLQ pain make this diagnosis unlikely.

• Peptic Ulcer Disease: Presents with epigastric pain, often related to meals or NSAID use. Pain is typically described as burning or gnawing, and not associated with right lower quadrant tenderness or leukocytosis, which are more consistent with appendicitis.

• Red blood cells count: The RBC count is within normal limits and does not aid in diagnosing appendicitis. It may be more relevant in cases of anemia, bleeding, or systemic illness but is not diagnostic in this scenario.

• Temperature: 100.8° F (38.2° C): A low-grade fever supports the presence of inflammation or infection. While nonspecific, it adds clinical weight to the suspicion of appendicitis when correlated with WBC elevation and CT results.

A. The client returned from appendectomy surgery last night at approximately 2100. The client was admitted for observation due to a delay in waking from anesthesia. B. The incision dressing is dry and intact, and no bleeding is noted. C. The client tolerated clear liquids post recovery and has advanced to a soft diet. D. The client ambulated around the unit this morning and tolerated activity well. E. Bowel sounds are present in all 4 quadrants, and per client report, she has passed flatus. Pain is tolerated with analgesia PO. F. The client is currently resting in bed.

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

Explanation

• Incision dressing is dry and intact, with no bleeding: Indicates proper wound healing and absence of complications such as infection or hemorrhage. A clean, dry surgical site is a key criterion for safe discharge.

• Tolerated clear liquids and advanced to soft diet: Shows that the gastrointestinal system is functioning post-anesthesia and surgery. Tolerance of oral intake without nausea, vomiting, or abdominal discomfort is essential before discharge.

• Ambulated around the unit and tolerated activity well: Demonstrates that the client has regained baseline mobility, which reduces risk of postoperative complications like atelectasis or DVT. Ability to mobilize is a standard requirement for safe discharge.

• Bowel sounds present in all four quadrants; passing flatus: Confirms the return of peristalsis and bowel function, which is necessary before discharge after abdominal surgery. Passing gas is an expected milestone indicating GI recovery.

• Pain controlled with oral analgesia: Suggests that the client’s pain is manageable without IV medication. Effective pain control at home using oral medications supports comfort and reduces the risk of readmission.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. The nurse recognizes that the client has ____ evidenced by ____. (Finding)

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

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

Explanation

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Client data

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