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Exhibits

Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again.

Nurses' Notes

2 weeks ago, 0940:

Client presents to clinic with reports of feeling unwell for the past few weeks. Client states, "I have a sore that won't get better on my right foot." Client removed gauze bandage to reveal open wound 3 cm x 4 cm on right foot; draining small amount of purulent drainage. Client awake and alert; chest clear to auscultation; heart tones audible with no abnormal heart tones heard. Client reports frequent urination, increased thirst, and recent 4.5 kg (10 lb) weight loss without trying. Client denies pain but reports experiencing nausea. BMI is 27.

Vital Signs

2 weeks ago, 0945

Temperature 38.3° C (100.9°F)

Heart rate 104/min

Respiratory rate 19/min

Blood pressure 98/74 mm Hg

Oxygen saturation 97% on room air

Laboratory Result

2 weeks ago, 1020:

WBC Count 9,500/mm3 (5,000 to 10,000/mm3)

Blood glucose 250mg/dL (74 to 106 mg/dL)

Triiodothyronine (T3) 200mg/dL (70 t0 205mg/dL)

Client states, "I have a sore that won't get better on my right foot." Client removed gauze bandage to reveal open wound 3 cm x 4 cm on right foot; draining small amount of purulent drainage

Client reports frequent urination, increased thirst, and recent 4.5 kg (10 lb) weight loss without trying. Client denies pain but reports experiencing nausea. BMI is 27

Temperature 38.3° C (100.9°F)

Heart rate 104/min

Respiratory rate 19/min

Blood pressure 98/74 mm Hg

Oxygen saturation 97% on room air

WBC Count 9,500/mm3 (5,000 to 10,000/mm3)

Blood glucose 250mg/dL (74 to 106 mg/dL)

Triiodothyronine (T3) 200mg/dL (70 t0 205mg/dL)

Answer and Explanation

The Correct Answer is ["A","B","C","D","F","I"]

Rationale for Correct Findings:

Open wound with purulent drainage: A non-healing wound with purulent drainage indicates a possible localized infection. In clients with hyperglycemia or diabetes, wounds are at higher risk for complications, including delayed healing and progression to systemic infection.
Client reports frequent urination, increased thirst, and recent 4.5 kg (10 lb) weight loss without trying. These are classic symptoms of hyperglycemia and potential new-onset diabetes mellitus which should be further evaluated.
Client reports experiencing nausea which could be related to hyperglycemia, infection, or other systemic issues.
Blood glucose 250 mg/dL: This value is significantly elevated and suggests poorly controlled blood glucose levels. Hyperglycemia impairs wound healing, increases infection risk, and can be a sign of undiagnosed or uncontrolled diabetes.
Temperature 38.3° C (100.9°F): A fever indicates a systemic inflammatory or infectious process. In combination with a draining wound and hyperglycemia, this raises concern for a potential infection requiring medical intervention.
Blood pressure 98/74 mm Hg: While not critically low, this borderline hypotensive value may reflect early signs of systemic infection or dehydration. It is especially concerning in the context of fever, tachycardia, and possible sepsis.
Heart rate 104/min: Tachycardia can be a compensatory response to fever, infection, or hypotension. When paired with fever and possible infection, it may indicate early sepsis or systemic involvement and warrants immediate reporting.

Rationale for Incorrect Findings:

WBC Count 9,500/mm³: This value falls within the normal range and does not alone suggest infection. However, WBC counts may remain normal in some clients with infections, especially those who are immunocompromised or have chronic conditions.
Respiratory rate 19/min: This is within the normal range and does not independently indicate respiratory distress or systemic compromise at this time.
Oxygen saturation 97% on room air: Oxygen saturation is adequate and suggests no immediate respiratory compromise. It does not require urgent attention in this scenario.
Triiodothyronine (T3) 200 mg/dL: This is within the normal range and unrelated to the client’s current presenting issues. Thyroid dysfunction is not suggested by the symptoms or labs at this time.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Flush the PICC line with 0.9% sodium chloride after medication administration: This is essential to maintain patency and prevent occlusion as it helps clear any medication residue from the line and ensures proper blood flow.

B. Monitor for a pneumothorax following insertion of the PICC line: A pneumothorax is a potential complication following the insertion of a central venous catheter in the subclavian or internal jugular vein, not typically associated with PICC line insertion.

C. Use a 3 mL syringe when flushing the PICC line: A 10 mL or larger syringe is recommended. Using a 3 mL syringe could generate high pressure, causing damage to the PICC line or the vein, leading to complications such as catheter rupture or vein injury.

D. Expect the PICC line to be inserted into a lower extremity vein: PICC lines are typically inserted into veins in the upper extremities, such as the basilic or cephalic veins. Inserting a PICC line into a lower extremity vein can increase the risk of complications such as DVT.

A. A client who had an appendectomy and has a urine output of 260 mL over 8 hr B. A client who is immobile and has had an episode of urinary incontinence C. A client who has COPD and an oxygen saturation of 99% D. A client who has a concussion and has developed aphasia

Correct Answer is D

Explanation

A. A client who had an appendectomy and has a urine output of 260 mL over 8 hr: A urine output of 260 mL over 8 hours is average (around 32.5 mL/hr), and it does not require immediate intervention. It is important to monitor, but there is no acute concern at this time.

B. A client who is immobile and has had an episode of urinary incontinence: While urinary incontinence can lead to skin breakdown and other issues, it is not immediately life-threatening. The nurse should address it with appropriate interventions, but it is not urgent.

C. A client who has COPD and an oxygen saturation of 99%: An oxygen saturation of 99% in a client with COPD is within normal limits. This indicates that the client’s respiratory status is stable and does not require immediate intervention.

D. A client who has a concussion and has developed aphasia: Aphasia after a concussion can indicate a serious complication, such as increased intracranial pressure or a brain injury. This requires immediate intervention to assess the severity of the condition and prevent further neurological damage.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who requires insertion of a peripherally inserted central catheter (PICC) line. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is caring for a group of clients on a medical unit. For which of the following clients should the nurse intervene immediately?

Correct Answer is D

Explanation

A nurse is assessing a client who has a stage 3 pressure injury. Which of the following findings indicates possible infection of the wound?

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