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Exhibits

Highlight the 3 orders that should be completed first.

Orders

Administer oxygen 5 L/minute via simple face mask

Vital signs ever 1 hour

X-ray of the right arm and cervical spin

Place 2 large bore peripheral IV's

Computed tomography scan of the brain

Give 1 Liter bolus of 0.9% sodium chloride solution IV once

Bacitracin applied topically to lacerations every 12 hours

Administer oxygen 5 L/minute via simple face mask

Bacitracin applied topically to lacerations every 12 hours

Place 2 large bore peripheral IV's

X-ray of the right arm and cervical spin

Computed tomography scan of the brain

Vital signs ever 1 hour

Give 1 Liter bolus of 0.9% sodium chloride solution IV once

Answer and Explanation

The Correct Answer is ["A","C","G"]

A. Administer oxygen 5 L/minute via simple face mask: Oxygen administration is a priority intervention to improve oxygenation and address the client's low oxygen saturation of 82%.
Hypoxemia can lead to tissue hypoxia and further compromise the client's condition. Therefore, administering oxygen should be the first action taken to ensure an adequate oxygen supply to vital organs.
B. Bacitracin applied topically to lacerations every 12 hours: While wound care is important, administering oxygen and establishing IV access take precedence over topical
treatment. Oxygenation and fluid resuscitation are critical in the immediate management of a trauma patient to ensure adequate tissue perfusion and oxygen delivery.

C. Place 2 large bore peripheral IV's: Establishing IV access is essential for administering medications and fluids rapidly. This is particularly important in this scenario where the client may require immediate fluid resuscitation due to hypotension (blood pressure of 83/41 mm Hg).
Large bore IV access allows for rapid infusion of fluids and medications to stabilize the client's hemodynamic status.

D. X-ray of the right arm and cervical spine: While diagnostic imaging is important for assessing injuries, it is not as urgent as administering oxygen and establishing IV access. Oxygenation and fluid resuscitation are higher priorities to stabilize the client's condition before proceeding with diagnostic tests.

E. Computed tomography scan of the brain: While a CT scan of the brain is essential for assessing potential head injuries, the immediate focus should be on stabilizing the client's oxygenation and hemodynamic status. Administering oxygen and fluids take precedence over diagnostic imaging to address the client's hypoxemia and hypotension.

F. Vital signs every 1 hour: Monitoring vital signs is important for ongoing assessment, but it is not as urgent as administering oxygen and fluids. Vital signs should be monitored closely, but immediate interventions to address hypoxemia and hypovolemia are critical to stabilize the client's condition.

G. Give 1 Liter bolus of 0.9% sodium chloride solution IV once: The client's hypotension (blood pressure of 83/41 mm Hg) indicates hypovolemia and the need for fluid resuscitation. Administering a bolus of intravenous fluids (1 Liter bolus of 0.9% sodium chloride solution) is essential to address hypovolemia and improve perfusion to vital organs. This intervention helps stabilize the client's blood pressure and prevent further deterioration of her condition.

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Correct Answer is D

Explanation

A. Begin abdominal girth measurements.
Abdominal girth measurements may be important for assessing fluid status in clients with liver disease and ascites, but in this case, the elevated polymorphonuclear leukocyte count indicates a possible infection, requiring immediate intervention.

B. Review serum protein levels.
While monitoring serum protein levels is important in clients with liver disease, the priority in this situation is to address the potential infection indicated by the elevated leukocyte count.

C. Assess neurological status.
Neurological assessment may be relevant in some cases, but it is not the priority in a client with suspected infection after a paracentesis.

D. Initiate antibiotic therapy.
Given the client's symptoms and the elevated polymorphonuclear leukocyte count in the ascitic fluid, indicating possible infection (spontaneous bacterial peritonitis), initiating antibiotic therapy is the priority action to address the infection and prevent further complications.

Correct Answer is []

Explanation

Cardiovascular

- Capillary refill 4 seconds

- A prolonged capillary refill time indicates poor peripheral perfusion, which can be a sign of hypoxia. Hypoxia can lead to reduced oxygen delivery to the tissues, resulting in delayed capillary refill.

Respiratory

- Oxygen saturation 90% on room air

- An oxygen saturation level of 90% is below the normal range (95-100%) and indicates that the blood is not adequately oxygenated, which is a direct sign of hypoxia.

- Respiratory rate 28 breaths/minute

- An elevated respiratory rate (tachypnea) is a common compensatory mechanism in response to hypoxia. The body attempts to increase oxygen intake and carbon dioxide expulsion by breathing more rapidly.

Neurological

- Anxious

- Anxiety can be a symptom of hypoxia. When the brain and other vital organs do not receive enough oxygen, it can trigger a sense of anxiety and restlessness as part of the body's alarm system.

- Restless

- Restlessness is another common symptom of hypoxia. It occurs because the body is trying to compensate for the lack of oxygen, leading to increased agitation and an inability to remain
calm.

Rationales for the Incorrect Choices:

- Cardiovascular

- Heart rate 101 beats/minute: While an elevated heart rate can be a compensatory response to hypoxia, it alone does not directly indicate hypoxia.
- Blood pressure 145/89 mm Hg: Elevated blood pressure is not a direct indicator of hypoxia and can be influenced by various factors including anxiety and pain.

- Respiratory

- Productive cough: A productive cough suggests respiratory infection or inflammation but does not directly measure oxygenation status or indicate hypoxia.

- Neurological

- Awake and alert: Being awake and alert indicates normal mental status and does not suggest hypoxia. Hypoxia typically affects cognitive function, leading to confusion or decreased level of consciousness in more severe cases.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with decompensated liver disease who is experiencing fever, chills, and abdominal tenderness. Following a paracentesis, the nurse receives laboratory results. Exhibits After notifying the healthcare provider, which action should the nurse take next?

Correct Answer is D

Explanation

Exhibits here The nurse places the client on a cardiorespiratory monitor and places the nasal cannula on the client. The nurse then completes an assessment and documents it in the chart. For each body system, click to specify the assessment findings that indicates hypoxia.

Correct Answer is []

Explanation

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