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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Rationale:
1. Working with an addiction therapist for several months will assist in my recovery. This statement reflects an acknowledgment of the importance of therapy in her recovery process, indicating an understanding of the treatment plan.
2. The Alcoholics Anonymous program would be a great resource, but they do not have meetings when I'm free.
While it acknowledges AA as a resource, it doesn't show an understanding of prioritizing meetings or seeking alternative solutions.
3. It is not safe for me to drink alcohol, but I am still able to smoke marijuana without problems.
This indicates a misconception; if alcohol is unsafe, other substances likely are too.
4. Identifying potential triggers allows me to proactively utilize coping strategies.
This statement demonstrates an understanding of the importance of identifying triggers and implementing coping strategies to prevent relapse, indicating engagement in the treatment process.
5. Relapse is an expected complication of substance use; thus, prevention strategies and awareness of my emotions are important.
Acknowledging relapse as a potential complication and recognizing the importance of prevention strategies and emotional awareness indicates a realistic understanding of the challenges associated with recovery.
6. The treatment options for alcoholism are limited to inpatients, with very few resources for outpatients.
This is factually incorrect and doesn't show understanding of the variety of treatment options available.
Correct Answer is B
Explanation
A. While the length of exposure can be relevant, it is not the most critical factor before starting isoniazid.
B. Isoniazid can cause hepatotoxicity, so a current diagnosis of hepatitis B is crucial to note as it increases the risk of liver damage.
C. A history of intravenous drug abuse is important for overall health assessment but is less critical than current liver disease.
D. Conversion of the PPD test indicates TB exposure, but assessing liver function and potential for hepatotoxicity is more urgent before starting the medication.
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