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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 B

Explanation

A. While it's important for the nurse to explain the need for education, the client's belief in personal benefits is more motivating.
B. The belief that their needs will be met through education fosters motivation.

C. Empathy from the nurse can enhance the learning experience but might not solely motivate the client.
D. Seeking family approval is an external motivator, but personal belief in the benefits of education is more intrinsic.

A. Administering antipyretic medication as needed B. Educating client and family on the importance of fluid restrictions C. Collaborating with dietician to prepare low protein diet D. Monitoring fluid status E. Investigating acid/base complication F. Assessing for worsening respiratory status G. Performing diagnostic testing to determine cause of fever H. Reassessing vital signs I. Identifying cardiac arrhythmias

Correct Answer is ["D","F","I"]

Explanation

A. Administering antipyretic medication as needed is important for managing the client's fever and improving comfort, but not as urgent as monitoring fluid, respiratory status, and cardiac function.
B. Client and family education on fluid management is important but can be addressed after assessing hydration status.
C. Protein restriction might be necessary for CKD management in the long term, but not the most pressing need right now.
D. Given the client's history of chronic kidney disease, monitoring fluid status is crucial to prevent fluid overload and ensure adequate kidney function. Accurate intake and output measurements, along with daily weights, are essential.
E. The bicarbonate level (18 mEq/L) is slightly low, but further investigation can come after addressing the infection.
F. The chest X-ray shows bibasilar infiltrates, and the client has a high respiratory rate.

Continuous assessment of respiratory status is important to detect any signs of respiratory distress or infection, which may require immediate intervention.
G. Performing diagnostic testing to determine cause of fever is necessary for identifying the underlying infection, but secondary to immediate stabilization efforts.
H. Reassessing vital signs is vital for ongoing assessment, but integrated into the monitoring of fluid status, respiratory status, and cardiac function.

I. The client has an elevated potassium level and an irregular heart rate, putting him at risk for cardiac arrhythmias. Continuous ECG monitoring and immediate identification of any arrhythmias are critical to prevent cardiac complications.

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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

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Explanation

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Explanation

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Exhibits

The nurse is caring for the client.

Which of the following assessment findings should the nurse prioritize?