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Patient Data

Exhibits

Click to highlight the assessment findings that require immediate follow up by the nurse.

Client is admitted to the medical floor. She has mild subcostal retractions and is sitting in an upright position. Wheezes are noted throughout the lung fields. The client is pale. She has strong peripheral pulses that are equal bilaterally. Her heart rate is 122 beats/minute, blood pressure 134/85 mm Hg, oxygen saturation 91% on room air.

mild subcostal retractions

Wheezes are noted throughout the lung fields

The client is pale

heart rate is 122 beats/minute

blood pressure 134/85 mm Hg

oxygen saturation 91% on room air

sitting in an upright position

Answer and Explanation

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

Mild subcostal retractions: Subcostal retractions indicate that the muscles between the ribs are pulling inward during breathing. This is a sign of increased work of breathing and can indicate respiratory distress.

Wheezes noted throughout the lung fields: Wheezing is a high-pitched whistling sound produced during breathing, typically due to narrowed airways. It indicates airway obstruction, common in asthma exacerbations.

Client is pale: Pallor (pale skin) can indicate reduced oxygenation or perfusion to the tissues, which can occur during respiratory distress.

Heart rate of 122 beats/minute: Tachycardia (elevated heart rate) is a compensatory mechanism in response to decreased oxygen levels or increased respiratory effort.

Oxygen saturation 91% on room air: Oxygen saturation below 94% indicates hypoxemia (low blood oxygen levels), which is a critical finding requiring prompt intervention.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

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

Explanation

Apply a body shrouding is appropriate as it covers the body, maintaining privacy and dignity. It's a common practice to cover the body with a sheet or shroud to ensure modesty.

B. Removing resuscitation equipment from the room is important to remove any reminders of medical interventions and procedures, allowing the family to focus on saying goodbye to their loved one without the presence of medical equipment that may be distressing.

C. Closing the eyes of the deceased is a respectful gesture in many cultures. It can create a peaceful appearance and is often considered a final act of care.

D. Place a small pillow under the head to support the head and neck in a more natural position. It helps create a more relaxed and comfortable appearance for the deceased.

E. Removing dentures is not typically done immediately after death, as it can alter the deceased's facial appearance.

NGNS

A. Notify information services department of the situation. B. Print electronic medical record (EMR) from backup server. C. Wait for notification that the system has been rebooted. D. Identify information as late entry in the record.

Correct Answer is A

Explanation

Rationale

A. Informing the information services department allows them to be aware of the issue promptly. They can then investigate the cause of the system failure and initiate appropriate measures to restore the system. It's important to involve IT professionals who are responsible for maintaining and troubleshooting the computer system.

B. While having access to patient information is crucial, printing from a backup server might not be immediately feasible or necessary if the primary system is expected to be restored soon. The nurse should first notify IT services to resolve the issue. If access to patient records is urgently needed and cannot be delayed, then printing from a backup server could be considered after notifying IT services.

C Waiting passively without taking action may delay the resolution of the issue. It's important for the nurse to proactively notify the information services department so they can begin troubleshooting and rebooting the system if necessary.

D. Labeling information as a late entry should only be considered once the system is back online and accessible. It should be done according to facility policies and procedures regarding late entries in medical records. However, this should not be the first action because the primary concern is to restore the functionality of the computer documentation system.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which intervention(s) should the nurse take to prepare the body before the family enters the room? Select all that apply.

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

Explanation

After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?

Correct Answer is A

Explanation

A client with septic shock develops disseminated intravascular coagulation (DIC). Which pathophysiologic process should the nurse recognize as the cause of the coagulation problem?

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?

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress,

An unresponsive victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save the client's life. The client is accompanied by a close friend, but no family members are available. Which action should the nurse take first?

The nurse is teaching an older client about the prevention of osteoporosis. Which foods should the nurse recommend to the client to increase in the diet?

A child who weighs 55 lb receives a prescription for cefotaxime 150 mg/kg/day IV in divided doses every 6 hours. How many mg should the nurse administer each day? (Enter numerical value only.)

Exhibits The nurse starts the albuterol nebulizer as prescribed. Which should the nurse assess after the albuterol nebulizer treatment is complete? Select all that apply.