Try Naxlex NCLEX-RN (Free-Trial)

Exhibits

The nurse reviews the nurse's notes and flow chart to identify trends.

Click to specify the notations that require immediate follow up (more than one notation may be correct.)

Body System

Circulatory

Heart rate 96 beats/minute

Blood pressure 90/62 mm Hg

IV infusing at 125 ml/hr

Respirations 16 breaths/minute

Respiratory

Oxygen saturation of 89%

Several deep breaths

Integumentary

Episiotomy intact with no redness

Pad is saturated with blood

18 gauge IV to left forearm

Genital/Urinary

Boggy fundus 1 cm above umbilicus

Fundus rotated to the right

Voided 200 mL of clear yellow urine

Blood pressure 90/62 mm Hg

Oxygen saturation of 89%

Fundus rotated to the right

Voided 200 mL of clear yellow urine

Oxygen saturation of 89%

IV infusing at 125 ml/hr

Answer and Explanation

The Correct Answer is ["A","B","C"]

Blood pressure 90/62 mm Hg

A blood pressure of 90/62 mm Hg indicates hypotension, which could be indicative of hypovolemia (low blood volume) due to postpartum hemorrhage. Hypotension needs immediate evaluation and intervention to prevent further complications.

Oxygen saturation of 89%

An oxygen saturation of 89% on room air is below the normal range (typically 95-100%). This suggests the client is not adequately oxygenating, which could be due to various reasons such as respiratory compromise or inadequate ventilation. Immediate follow-up is necessary to determine the cause and initiate appropriate interventions.

Fundus rotated to the right

The displacement of the fundus could be due to the presence of a distended bladder pushing the uterus to one side which may increase uterine atony.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale

A. JVD is typically an indicator of increased central venous pressure and can be associated with heart failure or fluid overload. In this scenario, flat JVD suggests decreased venous return, which may exacerbate the client's hypotension. While important, it may not be the most immediate concern compared to other options.

B. Changes in consciousness, such as confusion, disorientation, or loss of consciousness, are critical signs that indicate poor cerebral perfusion. In this case, the rapid ventricular rate and possibly inadequate cardiac output may not be meeting cerebral perfusion needs, leading to altered mental status. This finding requires urgent attention to prevent further deterioration.

C. Nausea and vomiting can indicate inadequate perfusion to the gastrointestinal tract due to hypotension or impaired cardiac output. While important to assess for fluid and electrolyte balance, it is less urgent compared to potential changes in mental status or perfusion to vital organs.

D. A sudden onset headache can be indicative of various issues, including hypertension, cerebral ischemia, or intracranial hemorrhage. However, in the context of atrial fibrillation with rapid ventricular response and hypotension, other neurological signs such as altered mental status or focal neurological deficits would typically be more concerning.

A. Apply ice then a warm compress to the IV site. B. Discontinue the IV site after inserting a new access. C. Redress the IV site while assessing for redness. D. Review the medical record for the date of insertion.

Correct Answer is B

Explanation

Rationale

A. Applying ice or a warm compress without assessing the site could potentially worsen any underlying issue.

B. The appropriate intervention would be to discontinue the IV site after ensuring a new access is established. This is because continuing to use a painful IV site can lead to complications such as infiltration or phlebitis.

C. Redressing the site without assessment does not address the client's complaint of pain.

D. Checking the medical record provides information about when the IV was inserted, which can be important for assessing the site's viability and expected duration. However, it doesn't address the immediate concern of the client's pain at the site or refusal of a flush.

View Question and Answer

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has developed atrial fibrillation with a ventricular rate of 150 beats/minute observed via telemetry. The client's blood pressure is 80/40 mm Hg. Which finding is most important for the nurse to report to the healthcare provider?

Correct Answer is B

Explanation

While preparing to administer a scheduled IV medication, the client tells the nurse that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement?

Correct Answer is B

Explanation

A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines. Which instruction should the nurse provide the parent about care of the infant after the injections?

The nurse is preparing a teaching plan for an older adult client diagnosed with osteoporosis. Which expected outcome has the highest priority for this client?

A client taking temazepam informs the nurse of plans to quit taking the medication due to feelings of "hungover" the next day. Which action should the nurse implement?

A client with a recent exacerbation of heart failure reports to the nurse feeling uncomfortable and anxious, with a sensation of the flopping in the chest. While waiting for an electrocardiogram (ECG), which assessment is most important for the nurse to obtain?

The nurse is assessing a 4-year-old client with eczema. The child's skin is dry and scaly, and the parent reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child?

When developing a teaching plan for a client with newly diagnosed type 1 diabetes mellitus, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?

Exhibits After the nurse assesses the client, the healthcare provider writes prescriptions. The nurse reviews the prescriptions. Which 2 prescriptions should the nurse complete first?