Exhibits
The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.
Blood pressure of 136/90 mm Hg
Oxygen saturation 95% on room air
Bone misalignment
Left arm that is cool to touch
Swelling at the site of injury
Nausea and fatigue reported by client
Intense pain reported by client
Decreased range of motion
Correct Answer : C,D,E,F,G
A. Blood pressure of 136/90 mm Hg while slightly elevated, is not unusual for someone in pain or distress and does not require immediate investigation.
B. Oxygen saturation 95% on room air is within the acceptable range for an adult and does not indicate immediate respiratory compromise.
C. The misalignment of the collarbone indicates a possible fracture or dislocation, which requires further assessment and imaging to confirm the extent of the injury.
D. A cool left arm could indicate compromised blood flow, possibly due to vascular injury from the trauma. This requires immediate investigation to prevent complications such as ischemia.
E. Swelling is a sign of trauma, which may indicate soft tissue damage, fractures, or inflammation. The nurse should monitor for further signs of internal bleeding or worsening injury.
F. Nausea and fatigue reported by client could suggest underlying issues such as a head injury, shock, or a systemic response to the trauma. Further evaluation is required to rule out serious complications like a concussion or other medical conditions.
G. Severe pain is a critical finding that needs prompt management. Pain assessment will guide the appropriate interventions, such as pain relief and further diagnostics to identify underlying causes.
H. While decreased range of motion is important, it is expected due to the trauma and pain from the fall. It will likely be addressed after the immediate concerns of injury and vascular status are managed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Notifying the healthcare provider about allergies to iodine or shellfish is crucial, as IVP contrast agents often contain iodine, and allergic reactions can occur. This is a safety measure that can prevent adverse reactions.
B. While keeping the legs straight may be necessary during the procedure, there is no requirement for them to be kept straight for 6 to 8 hours afterward.
C. While hydration is important, the focus should be on hydration after the procedure to help flush out the contrast material rather than specifically drinking large volumes before the procedure.
D. Inserting an indwelling urinary catheter is not routinely required for IVP unless specified by the healthcare provider; preparation usually focuses on the client’s hydration and allergy history.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"C"}
Explanation
Hemorrhaging:
The client exhibits signs of excessive vaginal bleeding, as indicated by a boggy fundus and saturated pads and sheets beneath her. The significant blood loss is concerning, especially following a 4th-degree laceration and the recent delivery.
Uterine Atony:
The fundus is noted to be boggy (soft) at multiple assessments, which is a key indicator of uterine atony. This condition is the most common cause of early postpartum hemorrhage and occurs when the uterus fails to contract effectively after delivery, leading to excessive blood loss.
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