Try Naxlex NCLEX-RN (Free-Trial)

Exhibits

Data is evaluated to determine possible condition and appropriate interventions. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

Condition:

Postoperative infection

2 Actions:

Administer prescribed antibiotics.
Culture wound drainage.

2 Parameters:

Temperature.
White blood cell count.

Rationale for correct condition:

A postoperative infection is the most likely condition because the patient has elevated white blood cell count (11,000/mm³) and a slightly elevated temperature (99.8°F). These findings suggest a systemic inflammatory response, potentially from infection. The presence of a recent surgical wound increases the risk of bacterial contamination. The absence of redness or drainage does not rule out deeper tissue infection. The patient’s symptoms align with early signs of an infectious process.

Rationale for the two correct actions:

Administer prescribed antibiotics: Antibiotics target potential bacterial infection, which is critical to prevent further complications such as systemic infection or sepsis.
Culture wound drainage: This identifies the causative organism and guides appropriate antibiotic therapy. Even if the wound appears clean externally, culturing can confirm or rule out deeper infection.

Rationale for parameters to monitor:

Temperature: Monitoring temperature helps identify trends in fever, a common sign of infection progression or resolution.
White blood cell count: Elevated levels are a marker of infection or inflammation. Monitoring changes in WBC count can indicate if treatment is effective.

Rationale for incorrect conditions:

Surgical rash: A rash is not indicated in the notes, and the elevated WBC count and temperature do not suggest a dermatologic issue.
Contractures: No evidence suggests reduced mobility or positioning problems causing contractures.
Deep vein thrombosis (DVT): The client’s normal vital signs and lack of redness or swelling in the residual limb make DVT less likely.

Rationale for incorrect actions to take:

Request NPO prescription: There is no evidence of gastrointestinal issues or surgery requiring this intervention.
Elevate residual limb to reduce swelling: While useful in managing swelling, there is no current sign of significant limb edema requiring elevation.
Educate on incentive spirometer use: This is preventive for respiratory complications but unrelated to infection management.

Rationale for incorrect parameters to monitor:

Adherence to activity prescription: While important for recovery, it does not directly address infection.
Residual limb redness or swelling: Although relevant to infection, there is no current evidence of redness or swelling in the notes.
Pain intensity and characteristics: Pain is already being managed with morphine, and its current level (5/10) does not directly indicate infection.

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 C

Explanation

Choice A reason: Wrapping the feet with warmed blankets may provide comfort and warmth, but it does not address the immediate concern of assessing the circulation status in the lower extremities. It is not the first action to take in this situation.

Choice B reason: Elevating the extremities on pillows can help reduce edema and improve circulation, but it should not be the first action taken. Assessing the pulses is crucial to determine the severity of the circulation issue and guide further interventions.

Choice C reason: Assessing pulses with a vascular doppler is the correct first action. Since the pedal pulses are not palpable, using a vascular doppler can help determine if there is any blood flow in the lower extremities. This assessment is essential to identify potential complications such as arterial occlusion or compromised circulation, which require immediate intervention.

Choice D reason: Evaluating edema for pitting can provide information about the extent of the swelling, but it does not address the immediate concern of assessing blood flow. Assessing pulses with a vascular doppler is a more critical first step to ensure the client's circulation status is evaluated accurately.

A. Take and monitor vital signs. B. Administer additional nebulizer treatment. C. Increase oxygen flow rate. D. Raise the head of the bed. E. Provide client with a spirometer for use.

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

Explanation

Choice A reason: Monitoring vital signs is crucial to assess the client's current condition and detect any further deterioration. Changes in vital signs can indicate the effectiveness of the treatment and whether additional interventions are needed. For instance, if the heart rate continues to rise or oxygen saturation drops further, it suggests that the client's condition is worsening and requires immediate attention. Keeping a close eye on the vital signs helps the healthcare team to make timely decisions and adjust the treatment plan as necessary.

Choice B reason: Administering additional nebulizer treatment is necessary because the client is still experiencing shortness of breath and bilateral wheezes even after the initial medication. Nebulizer treatments, such as those containing albuterol and ipratropium, help to relax and open the airways, making breathing easier. Given the client's severe asthma symptoms and the fact that the previous doses were not completely effective, additional treatment can provide the needed relief and prevent further respiratory distress.

Choice C reason: Increasing the oxygen flow rate is essential to improve the client's oxygen saturation levels. The current oxygen saturation of 91% indicates hypoxemia, which can lead to severe complications if not addressed promptly. By increasing the flow rate, the client can receive a higher concentration of oxygen, helping to maintain adequate oxygenation of tissues and organs. Continuous monitoring of oxygen saturation is also important to ensure that the increased flow rate is effective and to make further adjustments if needed.

Choice D reason: Raising the head of the bed helps to facilitate easier breathing for the client. This position allows gravity to assist in the expansion of the lungs and reduces the pressure on the diaphragm, making it easier for the client to take deeper breaths. It also helps to reduce the work of breathing and can be particularly beneficial for clients experiencing respiratory distress. Ensuring that the client is in a comfortable and optimal position for breathing is an important aspect of asthma management.

Choice E reason: While providing a spirometer can be useful for lung function exercises, it is not the immediate priority in this acute situation. The client's primary concern is to stabilize their breathing and ensure adequate oxygenation. Once the client is stable, a spirometer can be introduced as part of long-term management and rehabilitation to improve lung function and monitor progress.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?

Correct Answer is C

Explanation

Exhibits After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

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

Explanation

A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?

A client who takes daily supplemental iron tablets for iron deficiency anemia reports feeling increasingly fatigued. Which laboratory value should the nurse review?

A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instruction should the nurse provide?

A client receives a prescription for 2 liters of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 20 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Exhibits Complete the diagram by choosing from the choices below to specify which condition the client is most likely experiencing, two actions the nurse should take to address the condition, and two parameters the nurse should monitor to assess the client's progress.

The nurse assesses an adult client 24 hours after a bowel exploration and formation of a sigmoid colostomy. Which assessment finding should be reported to the surgeon immediately?

The nurse is assessing a client who is one day postoperative parathyroidectomy and finds that the client is experiencing stridor. After notifying the healthcare provider (HCP), the nurse should prepare for which procedure?

A client who is experiencing a first gouty arthritis attack reports excruciating pain in the right great toe. The nurse inspects the inflamed joint and administers ibuprofen 800mg PO as prescribed. Which instruction should the nurse include in the discharge teaching?