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Exhibits

The nurse is caring for the client.

Which of the following assessment findings should the nurse prioritize?

Heart rate 121 beats/minute

Capillary refill 2 seconds

Respirations 28 breaths/minute with shallow breathing

Radial and pedal pulses 2+

Severe abdominal pain in right lower quadrant

Feels anxious

Temperature 100.8° F (38.2° C)

Vomiting small amounts of green bile

Blood pressure 115/76 mm Hg

Answer and Explanation

Correct Answer : A,C,E,G,H

A.   Tachycardia indicates the body is responding to pain, infection, or potential sepsis. It's a critical vital sign indicating the body's stress response.
B.   Tachypnea can be a response to pain or anxiety but also indicates the need for careful monitoring of respiratory status, especially postoperatively.

C.   A capillary refill of 2 seconds is within the normal range and indicates adequate peripheral perfusion.
D.   Radial and pedal pulses 2+ are within the normal range and indicates adequate peripheral perfusion.
E.   Severe abdominal pain in the right lower quadrant is a primary symptom of appendicitis, which is confirmed by the CT scan showing a dilated appendix and fat stranding. Immediate attention is needed to address potential complications such as rupture.
F.   Feeling anxious needs to be managed to promote patient comfort. However, it doesn’t need to be managed immediately since it is not life-threatening.
G.   Fever is a sign of infection or inflammation, common in appendicitis. Monitoring and managing fever is crucial in preventing further complications.
H.   Bilious vomitus is a common finding in appendicitis and may indicate that the inflammation has progressed to a point where it is causing a blockage in the intestines. This obstruction can lead to increased pressure within the abdominal cavity and compromise blood flow, potentially resulting in a life-threatening situation.
I.   A blood pressure of 115/76 mm Hg is within normal limits and indicates stable hemodynamics at this point.

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

Explanation

A. Early ambulation helps prevent complications such as atelectasis, pneumonia, and deep vein thrombosis (DVT). It also promotes intestinal motility.
B. Monitoring for bleeding should be more frequent, especially in the immediate postoperative period, rather than just once daily.
C. This helps prevent respiratory complications such as atelectasis and promotes lung expansion.
D. Adequate hydration is essential to maintain fluid balance, promote healing, and prevent complications such as urinary tract infections and constipation.
E. Monitoring for sedation is crucial to ensure that pain medications are not causing excessive drowsiness, which could impair the client's ability to participate in activities such as ambulation and use of the incentive spirometer.

F. While assessing neurological status is important, frequent neurological assessments are more relevant for clients with neurological conditions or concerns. In this case, routine assessments should be sufficient unless the client has specific neurological symptoms.
G. Pain medications should be administered prophylactically before activity. However, it can also be administered after activity in case the client complains of pain.

A. Tell me about the activities that cause your pain? B. Does your pain occur when walking short distances? C. When did you first notice the pain in your chest? D. How do you feel when the pain becomes noticeable?

Correct Answer is B

Explanation

A. This is an open-ended question, not closed-ended.

B. A closed-ended question like "Does your pain occur when walking short distances?" is specific and allows the nurse to understand the triggers and pattern of the pain, which is important for assessing unstable angina.
C. "When did you first notice the pain in your chest?" is also a relevant question but less specific to understanding the current pattern and triggers of the pain.
D. "How do you feel when the pain becomes noticeable?" is open-ended and less specific in identifying triggers and patterns of the pain.

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Exhibits The nurse is caring for the client. Which of the following assessment findings should the nurse prioritize?

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Click to select the 5 most important nursing interventions for postoperative client care.

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

Explanation

While completing an admission assessment for a client with unstable angina, which closed ended questions should the nurse ask about the client's chest pain?

Correct Answer is B

Explanation

Patient Data Exhibits Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.

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Exhibits

The nurse is caring for the client.

Which of the following assessment findings should the nurse prioritize?