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Exhibits

Highlight the assessment findings that require follow-up by the nurse.

The client is postoperative below-the-knee amputation right leg day 3. He is sitting up with his left leg and right leg residual limb hanging off the bed. There is client-controlled analgesia (PCA) of morphine on demand in the left hand area; there is no redness at the site with 0.9% sodium chloride infusing at 50 mL an hour.

General: Alert, oriented to person, place, and time.

Eyes Pupils round, reactive to light and accommodation (PERRLA).

Lungs: Lungs clear all lobes.

Heart Telemetry monitor displaying sinus rhythm (SR).

Abdomen: Abdomen soft, bowel sounds in all 4 quadrants. Denies pain with urination and describes urine as light yellow.

Right leg: Right leg incision is open to air skin to the area is cool to touch and edema noted along the incision. Sutures intact, no redness noted, popliteal pulses strong bilaterally and wound drain with approximately 100 ml of drainage present on right leg. Reports pain is a 2 on a 0 to 10 scale, right residual limb area.

Left leg 2+ pedal pulse loss of hair on the lower leg, skin is dry, scaly, cool to touch, thickened toe nails noted, and capillary refill is greater than 4 seconds

cool to touch and edema noted along the incision

wound drain with approximately 100 ml of drainage present

loss of hair on the lower leg

right residual limb area.

capillary refill is greater than 4 seconds

Answer and Explanation

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

Right leg: Skin cool to touch with edema along the incision: These signs suggest impaired perfusion and possible early infection or inflammation. Although there's no redness, edema and coolness warrant continued monitoring for progression or signs of infection.
Right leg: 100 mL of wound drainage present: This is a moderately high amount of drainage for postoperative day 3. While not yet excessive, the color, consistency, and ongoing amount must be monitored closely for signs of infection or wound dehiscence.
Left leg: Loss of hair on lower leg, dry/scaly/cool skin: These are classic signs of chronic peripheral arterial disease (PAD), reflecting poor circulation. This limb is also at risk for ischemia and future complications, especially with the client's history of PVD and a recent amputation on the opposite leg.
Left leg: Thickened toenails: This indicates chronic poor circulation and possibly fungal infection or tissue ischemia. It reflects long-standing vascular compromise and should be documented and evaluated by vascular or podiatry teams.
Left leg: Capillary refill greater than 4 seconds: This is a clear indicator of impaired peripheral perfusion. Normal refill is under 2 seconds; delayed refill confirms compromised blood flow and requires further vascular evaluation or intervention.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A","dropdown-group-3":"C"}

Explanation

Appendicitis: The client presents with sudden onset right lower quadrant pain, fever, nausea, and vomiting, which are classic signs of appendicitis. The pain’s location between the umbilicus and iliac crest aligns with the anatomical position of the appendix. Appendicitis is also supported by imaging and lab findings consistent with inflammation and infection.
Cholecystitis: This condition is characterized by right upper quadrant abdominal pain, often radiating to the back or shoulder, typically triggered by fatty food intake. It is frequently accompanied by a positive Murphy’s sign, which was not reported here. The location and nature of the client’s pain do not match the presentation of cholecystitis.
Urinary tract infection: UTIs usually present with symptoms such as urinary frequency, urgency, burning with urination, or suprapubic discomfort. The client explicitly denies burning or urinary symptoms, and genitourinary assessment was within normal limits. These findings make a UTI an unlikely cause of her abdominal pain.
CT scan results: The CT scan revealed a dilated appendix (7 mm) with fat stranding, both hallmark signs of acute appendicitis. A normal appendix is typically less than 6 mm in diameter. Fat stranding suggests surrounding inflammation, providing radiologic confirmation of the suspected diagnosis.
Pain localized to the epigastric region: Epigastric pain is more often associated with gastritis, pancreatitis, or peptic ulcer disease. The client’s pain is localized to the right lower quadrant, not the epigastric area, making this finding inconsistent with her presentation and not supportive of appendicitis.
White blood cell count (WBC): An elevated WBC count of 16,000/mm³ suggests the presence of a systemic inflammatory response, which commonly occurs in appendicitis. This lab value supports the clinical suspicion of infection and inflammation of the appendix.
Normal bowel sounds and soft, non-tender abdomen: This finding would suggest no significant intra-abdominal pathology or inflammation. In this case, the abdomen is tender with localized severe pain in the right lower quadrant, making this finding unrelated and inconsistent with the diagnosis.

A. Thready pulse, hypotension, and chest or back pain. B. Urticaria, itching, and wheezing. C. Bounding pulse, hypertension, and distended neck veins. D. Chills, fever, and tachycardia.

Correct Answer is C

Explanation

A. Thready pulse, hypotension, and chest or back pain: These findings are more consistent with hypovolemia or potential blood transfusion reactions like acute hemolytic reaction or internal bleeding, not fluid overload. They suggest a volume deficit rather than excess.

B. Urticaria, itching, and wheezing: These are classic signs of an allergic reaction or anaphylaxis due to a transfusion, not fluid overload. While serious, they reflect hypersensitivity rather than excessive fluid volume.

C. Bounding pulse, hypertension, and distended neck veins: These are hallmark signs of fluid overload, especially in older adults who may have reduced cardiac or renal reserve. Fluid overload increases preload, leading to elevated blood pressure, jugular venous distention, and strong, bounding pulses.

D. Chills, fever, and tachycardia: These symptoms are more suggestive of a febrile non-hemolytic transfusion reaction or sepsis. Although important, they are not signs of volume overload and indicate a different type of transfusion complication.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits 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 dropdown evidenced by dropdown and dropdown.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A","dropdown-group-3":"C"}

Explanation

The nurse is administering the second unit of whole blood to an older adult client who was admitted yesterday with gastrointestinal (GI) bleeding. Which parameters should the nurse monitor that indicate fluid overload?

Correct Answer is C

Explanation

Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires Immediate action by the nurse? Reference Range: Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]

When explaining dietary guidelines to a client with acute glomerulonephritis (AGN), which instruction should the nurse include in the dietary teaching?

Which client has the highest risk for developing skin cancer?

A client with a new diagnosis of glaucoma is concerned about going blind. To help prevent blindness due to glaucoma, the nurse should instruct the client to implement which action(s)? Select all that apply.

Exhibits 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.

A client with chronic syndrome of inappropriate antidiuretic hormone (SIADH) reports to the nurse of being constantly thirsty. Which action should the nurse take?

A client with eczema is applying 10% urea cream onto the affected skin areas. Which finding reflects the expected therapeutic response?