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.
Bone misalignment
Decreased range of motion
Left arm that is cool to touch
Swelling at the site of injury
Blood pressure of 136/90 mm Hg
Intense pain reported by client
Oxygen saturation 95% on room air
Correct Answer : A,B,C,D,F
A. Bone misalignment - The nurse’s notes mention that the collarbone appears out of alignment on the left side. This could indicate a fracture or dislocation and should be investigated further.
B. Decreased range of motion - The client reports an inability to move his left arm. This could be due to the pain or a result of the injury and should be investigated further.
C. Left arm that is cool to touch - Decreased temperature in a limb can indicate poor circulation, which could be a result of the injury. This should be investigated further.
D. Swelling at the site of injury - Swelling and bruising are present on the client’s shoulder. This is a common sign of injury and should be investigated further.
E. Blood pressure of 136/90 mm Hg - While this blood pressure is not extremely high, it is on the higher end of normal. Given the client’s age and the stress of the situation, it would be worth monitoring.
F. Intense pain reported by client - The client reports a pain rating of 10 on a 0 to 10 scale in the left arm. This level of pain is concerning and should be addressed.
G. Oxygen saturation 95% on room air - While an oxygen saturation of 95% is within the normal range, given the client’s recent trauma and reported nausea, it would be prudent to monitor this closely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
In a patient with a recent exacerbation of heart failure who is feeling uncomfortable and anxious, with a sensation of flopping in the chest, the rhythm of the apical pulse should be prioritized. This is because changes in heart rhythm can indicate worsening heart failure or other serious cardiac conditions.
Choice B rationale
While the volume of pedal pulses can provide information about peripheral circulation, it is not as immediately relevant as the rhythm of the apical pulse in a patient with heart failure experiencing discomfort and anxiety.
Choice C rationale
The degree of skin elasticity can provide information about hydration status, but it is not as immediately relevant as the rhythm of the apical pulse in a patient with heart failure experiencing discomfort and anxiety.
Choice D rationale
The length of capillary refill can provide information about peripheral circulation and overall cardiovascular status, but it is not as immediately relevant as the rhythm of the apical pulse in a patient with heart failure experiencing discomfort and anxiety.
Correct Answer is C
Explanation
Choice A rationale
While repeat blood cultures could potentially provide useful information, they are not the immediate priority when a patient develops jaundice. Jaundice is a sign of liver dysfunction, and further evaluation of liver function is needed to determine the cause and appropriate treatment.
Choice B rationale
Arranging emergency transport to an inpatient facility may be necessary in some cases, but it is not the immediate action required in this situation. The development of jaundice indicates a need for further evaluation, but it does not necessarily indicate an emergency situation.
Choice C rationale
Explaining the need to evaluate liver function is the most appropriate action in this situation. Jaundice is a sign of liver dysfunction, and further evaluation of liver function is needed to determine the cause and appropriate treatment.
Choice D rationale
While increasing protein intake can be beneficial for some patients with liver disease, it is not the immediate priority in this situation. The development of jaundice indicates a need for further evaluation of liver function.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.