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Exhibits

Review H and P and nurse's notes.

Click to highlight which assessment findings should the nurse attend to right away?

Admitted client. Vital signs: heart rate 128 beats/minute, rhythm sinus tachycardia, respiratory rate 14 breaths/minute, oxygen saturation 100% on 40% fraction of inspired oxygen, temperature 96.9° F (36.1° C), blood pressure 90/79 mm Hg. Pulse pressure calculated to be less than 40 mm Hg. The client's surgical dressing is clean and dry. Ecchymosis noted on the abdomen around the dressing. The client has a peripheral intravenous line in the right forearm and one in the left hand. The client also has a right subclavian central venous catheter that is infusing propofol and intravenous fluids. Heart sounds are regular. The skin is pink. Capillary refill is 6 seconds. Radial pulses are equal bilaterally. Lung sounds are clear and equal bilaterally. The client has an indwelling urinary catheter in place. No urine noted. The client has no visitors at this time. The social worker is attempting to contact family members. The client opens her eyes to verbal stimuli and follows verbal commands.

heart rate 128 beats/minute, rhythm sinus tachycardia

respiratory rate 14 breaths/minute

oxygen saturation 100% on 40% fraction of inspired oxygen

temperature 96.9° F (36.1° C)

blood pressure 90/79 mm Hg

Pulse pressure calculated to be less than 40 mm Hg

The client's surgical dressing is clean and dry

Ecchymosis noted on the abdomen around the dressing

Capillary refill is 6 seconds

Radial pulses are equal bilaterally

Lung sounds are clear and equal bilaterally

No urine noted

Answer and Explanation

The Correct Answer is ["A","D","E","F","H","I","L"]

Rationale for Correct Choices:

Heart rate 128 beats/minute, sinus tachycardia: The elevated heart rate of 128 beats/minute suggests tachycardia, which could indicate hypovolemia or shock, especially given the traumatic nature of the injury. This warrants immediate attention to prevent cardiovascular compromise.
Temperature 96.9° F (36.1° C): A low temperature is concerning in trauma patients and could indicate hypothermia, which worsens in a critical setting. It should be monitored closely and actively managed, especially in the ICU setting.
Blood pressure 90/79 mm Hg, pulse pressure less than 40 mm Hg: A pulse pressure of less than 40 mm Hg can be a sign of insufficient perfusion and is concerning in trauma. The low blood pressure in combination with the narrowed pulse pressure suggests the possibility of hemorrhagic shock, which requires immediate intervention to stabilize blood volume.
Ecchymosis noted on the abdomen around the dressing: Ecchymosis around the abdominal dressing, combined with the history of trauma and CT findings of liver and spleen lacerations with peritoneal blood, strongly indicates ongoing internal bleeding.
Capillary refill is 6 seconds: Delayed capillary refill is a sign of poor peripheral perfusion, which can be indicative of hypovolemic shock or other circulatory compromise. This finding should be addressed promptly to assess circulatory status and address underlying causes.
No urine noted in the indwelling urinary catheter: The absence of urine output is a critical finding, especially in a trauma patient. It may indicate renal hypoperfusion due to low blood pressure, which can lead to acute kidney injury.

Rationale for Incorrect Choices:

Respiratory rate 14 breaths/minute: A respiratory rate of 14 breaths/minute is within the normal range for an adult. There are no signs of respiratory distress, so it does not require urgent attention at this time.
Oxygen saturation 100% on 40% fraction of inspired oxygen (FiO2): The oxygen saturation is 100%, which is within the normal range. The use of 40% FiO2 is appropriate for intubated patients, and no immediate intervention is needed for oxygenation at this time.
Surgical dressing is clean and dry: The surgical dressing being clean and dry suggests there is no active bleeding at the moment, it does not require urgent intervention unless there are signs of worsening or internal bleeding.
Lung sounds are clear and equal bilaterally: Clear lung sounds indicate that there are no immediate respiratory issues such as fluid buildup or obstruction. This is a positive finding and does not require urgent attention 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":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Rationale:

Palpate and compare radial pulses: It is important to check radial pulses to assess circulation to the injured limb. Decreased pulse strength, especially in the left arm, could indicate vascular injury, which requires immediate attention.
Administer ondansetron 4 mg IV: The client is feeling nauseated and worries about vomiting, likely due to postoperative effects, pain medication, or anesthesia. Ondansetron is an antiemetic, which is appropriate to administer to manage nausea and prevent vomiting.
Check capillary refill on bilateral upper extremities: Checking capillary refill is essential to assess perfusion to both arms. The client’s left arm is experiencing coolness, and diminished pulses were noted earlier, so this is necessary to monitor blood flow and prevent complications like compartment syndrome.
Inspect the bandage for drainage: After surgery, it is important to inspect the surgical site for any drainage, bleeding, or signs of infection. This helps ensure that there are no complications or issues with wound healing.

Perform range of motion: Performing range of motion exercises is contraindicated immediately after trauma, especially with a fracture or suspected injury to the shoulder. The shoulder should be immobilized to prevent further damage and to facilitate proper healing. Early movement may worsen the injury or cause additional pain.
Provide morphine 2 mg IV push (IVP): While he had a nerve block, its effectiveness will wane, and he will likely experience significant pain from the fracture and surgical manipulation. Administering prescribed analgesia like morphine is a priority for pain management.

A. Offer the client to move to a quiet room first. B. Allow the client time to complete her sentence. C. Pull up a chair and sit quietly with the client. D. Provide a list of phrases to express her-self properly.

Correct Answer is B

Explanation

A. Offer the client to move to a quiet room first: Changing the environment may reduce distractions, but it does not directly support the client’s immediate attempt to communicate. The priority is to respond to the client’s active effort to speak in the moment.

B. Allow the client time to complete her sentence: Allowing extra time promotes autonomy, reduces frustration, and respects the communication process for clients with aphasia. It gives the client space to formulate thoughts without pressure or interruption, which supports language recovery and expression.

C. Pull up a chair and sit quietly with the client: Sitting quietly can offer emotional support, but it may be perceived as passive when the client is actively trying to communicate. The nurse should take a facilitative role by giving the client time to speak, rather than only offering silent presence.

D. Provide a list of phrases to express herself properly: Providing phrases may overwhelm or confuse the client, especially during spontaneous attempts to speak. Aphasia affects word retrieval, and prompting with choices may interrupt the client's cognitive effort.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse reviews the prescriptions and plans initial steps for caring for the client. Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

A female client with aphasia is trying to verbalize feelings to the nurse and states, "I want...," but does not finish the statement. How should the nurse respond to this unfinished statement?

Correct Answer is B

Explanation

The healthcare provider prescribes dalteparin 200 units/kg SUBQ once a day for a client who weighs 154 lb. The medication is available in 25,000 units/mL vial. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

Which laboratory values are critical for the nurse to monitor for a client who is experiencing a thyrotoxic crisis?

Exhibits Drag from Word Choices to complete the sentence. According to the lab values, the client has dropdownrelated to dropdownordropdown.

The nurse is administering multiple prescribed vaccines to a toddler. Which strategy should the nurse prioritize to reduce the duration of pain?

The parent of a child born with a myelomeningocele asks the nurse, "What did I do to deserve this?" Which response is most helpful?

Exhibits Which information from the history and physical, nurses' note, and flow sheet requires further evaluation? Select all that apply.

The nurse is preparing an older adult client for discharge following cataract extraction. Which instruction should be included in the discharge teaching?

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.