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 A

Explanation

A. Position bedside table so the client can lean across it: Leaning forward, or assuming a tripod position, can help relieve pressure on the inflamed pancreas and ease epigastric pain, so positioning a bedside table for support offers comfort and facilitates better breathing.

B. Encourage rest until the analgesic becomes effective: Although rest is beneficial, simply encouraging the client to wait disregards their active attempts to find a position that eases their pain, potentially worsening discomfort and anxiety.

C. Raise head of bed until to a 90 degree angle: Elevating the head of the bed may provide partial relief but does not offer the same effectiveness as allowing the client to lean forward, which specifically reduces intra-abdominal pressure.

D. Place bed in a reverse trendelenburg position: Reverse Trendelenburg reduces pressure on abdominal organs by elevating the head and torso, but it is less effective for relieving pancreatitis-related pain compared to leaning forward with upper body support.

A. Note date and time of the behavior. B. Discuss the issue privately with the UAP. C. Plan for scheduled break times. D. Evaluate the UAP for signs of improvement.

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.

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

A client with pancreatitis reports severe epigastric pain, so the nurse administers a prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement?

Correct Answer is A

Explanation

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

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

The nurse is planning discharge instructions for a client with type 2 diabetes mellitus who will be starting exenatide. Which information should be included in the discharge instructions?

The home health nurse makes a home visit to a client with amyotrophic lateral sclerosis (ALS). The client is sitting upright while feeding themself and coughs frequently during the meal. Which action should the nurse implement?

The nurse is caring for a client who reports running out of aspirin 1 week ago and taking ibuprofen as a replacement. Which information should the nurse obtain from the client first?

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

A client with hemorrhoids asks for information about a high fiber diet. Which breakfast menu item(s) should the nurse suggest? Select all that apply.

Client data

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