Exhibits

The nurse has completed a client history and initial assessment and is now planning and prioritizing care of the client.

Complete the following sentences by choosing from the lists of corresponding options.

Based on history and assessment data, the nurse should prioritize
_
as the priority problem for this client, as evidenced by the client’s statement
_

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Based on history and assessment data, the nurse should prioritize activity intolerance as the priority problem for this client, as evidenced by the client's statement "I just can't catch my breath."

Rationale:

Activity intolerance: The client's shortness of breath and wheezing indicate impaired gas exchange and reduced oxygenation, which limits their ability to engage in physical activity.
Anxiety: While anxiety can exacerbate asthma symptoms, the immediate priority is to address the physiological issue of impaired gas exchange.

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Correct Answer is D

Explanation

A. Throbbing pain can be a common response after a fracture and cast application but does not necessarily indicate an emergency situation.

B. Circumferential edema could suggest complications, but it is not as immediately concerning as the vascular status of the limb.

C. An increased temperature in the lower extremity could indicate inflammation or infection, but it does not require immediate intervention compared to signs of impaired circulation.

D. A pale foot with sluggish capillary refill suggests compromised blood flow, which is a medical emergency requiring immediate assessment and intervention to prevent ischemia or compartment syndrome.

A. Hemoglobin levels. B. Red blood cell count. C. White blood cell count. D. Platelet count.

Correct Answer is D

Explanation

A. Hemoglobin levels can indicate anemia but are not directly related to the presence of petechiae and ecchymosis, which suggest bleeding issues.

B. The red blood cell count is also important for understanding anemia but does not specifically address the bleeding disorders indicated by the client’s symptoms.

C. The white blood cell count provides information on the immune status but does not relate to bleeding manifestations.

D. The platelet count is critical to assess because petechiae and ecchymosis can be indicative of thrombocytopenia (low platelet count), which can lead to increased bleeding tendencies. Monitoring platelet levels will help determine the cause of these symptoms.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After falling down the basement steps, a client is brought to the emergency room. The x-ray confirms the client's right leg is fractured. Following the application of a leg cast, which assessment finding warrants immediate intervention by the nurse?

Correct Answer is D

Explanation

The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?

Correct Answer is D

Explanation

A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI. Which parameters are most important for the nurse to plan to carefully monitor?

The nurse is caring for a client who tests positive for the sexually transmitted infection (STI) gonorrhea. The client reports having sex with someone who has many partners. Which response should the nurse provide?

The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?

When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include?

The nurse is caring for a client who tests positive for the sexually transmitted infection (STI) gonorrhea. The client reports having sex with someone who has many partners. Which response should the nurse provide?