Exhibits

The healthcare provider places orders to determine the cause of client symptoms.

Use the chart to indicate if the listed symptom or finding is consistent with gastroenteritis, appendicitis, or ectopic pregnancy.

Each row must have at least one, but may have more than one, response option selected.

Fever

Tachycardia

Nausea

Vomiting

Diarrhea

Answer and Explanation

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

Fever is a common symptom that can be present in gastroenteritis, appendicitis, and, less commonly, ectopic pregnancy. Tachycardia may occur in all three conditions but is more commonly associated with ectopic pregnancy, especially if there is internal bleeding. Nausea and vomiting are symptoms that can be seen in gastroenteritis and appendicitis, and occasionally in ectopic pregnancy. Diarrhea is most commonly associated with gastroenteritis.

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Correct Answer is D

Explanation

A. Reinflating the cuff to a higher number may not resolve the issue and can lead to unnecessary discomfort.

B. An auscultatory gap occurs when Korotkoff sounds disappear temporarily after being heard and then reappear. Here, the scenario describes silence followed by the first Korotkoff sound,which is normal, not a gap.

C. Repositioning the stethoscope over the brachial artery may not help if the auscultatory gap is the issue.

D. When measuring blood pressure, it is normal to first hear silence after inflation until the pressure in the cuff falls just below the systolic pressure, at which point the first Korotkoff sound appears. That first sound marks the systolic blood pressure. Therefore, the nurse should continue deflating the cuff and completing the measurement to identify both systolic and diastolic pressures accurately.

A. Place ice packs around the client's head B. Microwave a pack of gauze and distribute across the body C. Administer intravenous fluids with a rapid infuser D. Check the temperature of the humidified oxygen attached to the ventilator E. Instill warm fluids in the nasogastric tube F. Use a fluid warmer for intravenous fluids G. Apply warm blankets H. Administer an antipyretic

Correct Answer is ["C","D","E","F","G"]

Explanation

A. Place ice packs around the client's head: This is a cooling intervention used for hyperthermia, not for treating hypothermia.
B. Microwave a pack of gauze and distribute across the body: This is unsafe, as microwaved materials can cause burns and do not provide effective heat distribution.
C. Administer intravenous fluids with a rapid infuser: Rapid infusion of warmed IV fluids can help restore core body temperature and prevent further hypothermia.
D. Check the temperature of the humidified oxygen attached to the ventilator: Cold or dry oxygen can contribute to heat loss, so ensuring that the humidified oxygen is warmed is an important step in maintaining normothermia.
E. Instill warm fluids in the nasogastric tube: Lavage with warm fluids via NG tube is an effective method of internal warming for hypothermic patients.
F. Use a fluid warmer for intravenous fluids: Warming IV fluids before administration prevents additional heat loss that could occur if room-temperature fluids are given.
G. Apply warm blankets: Passive external warming using warm blankets is an easy and effective intervention to increase body temperature.
H. Administer an antipyretic: Antipyretics (e.g., acetaminophen, ibuprofen) are used for fevers, not for hypothermia.

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Naxlex Comprehensive Predictor Exams

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

Correct Answer is D

Explanation

Exhibits The nurse is concerned about the client's temperature. Which interventions can the nurse use to address the client's temperature? Select all that apply.

Correct Answer is ["C","D","E","F","G"]

Explanation

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