Patient Data

Exhibits

Review was done of H and P, nurses' notes, and orders.

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.

Answer and Explanation

The Correct Answer is []

Pressure sores are divided into different stages:

Stage 1= Intact skin with non-blanchable redness over a localized area

Stage 2= Partial thickness loss of dermis, shallow open ulcer with a pink base

Stage 3= Full thickness ulcer but tendons, muscles and bone are not exposed

Stage 4- Full thickness wound with exposed tendons, muscle and bone

Unstageable-Full thickness tissue loss with the base covered with an eschar or yellow, gray or brown tissue

The client already has a pressure sore that requires cleaning to remove any tissue debris that may act as nidus for infection, placing a hydrocolloid dressing protects and debrides the wound to promote healing Monitoring skin integrity is key to ensure no other pressure sores develop.

Nutritional status determines the risk of developing pressure injury and the chances of wound healing.

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Correct Answer is A

Explanation

A. If the popsicles are completely frozen. This is the most crucial information in this scenario. Clear liquids are recommended for a child who has been vomiting, and if the popsicles are not completely frozen, they may contain solid particles or ingredients that could worsen the child's condition.
B. Knowing the quantity of popsicles available can help the nurse assess the child's potential intake of fluids and ensure that an adequate supply is on hand if needed.
C. The color and flavor of gelatin used is important because certain colors and flavors of gelatin may contain additives or artificial ingredients that could potentially worsen the child's condition or cause discomfort.
D. While it’s important that clear liquids do not contain pulp or solid materials, in this scenario, the immediate concern is the state of the popsicles (frozen or not) rather than their composition.

A. Radial pulse volume is 3+. B. Capillary refill time is 2 seconds. C. Blood pressure is 142/88 mm Hg. D. 2+ edema of fingers and hands.

Correct Answer is D

Explanation

D. Edema of the fingers and hands can impair circulation and peripheral perfusion, which may affect the accuracy of oxygen saturation readings obtained from a pulse oximeter. Edema can interfere with the transmission of light through the tissues, leading to inaccurate readings.
A. A strong radial pulse volume indicates adequate peripheral perfusion and may not directly contribute to a lower oxygen saturation reading.
B. A capillary refill time within the normal range (typically less than 2 seconds) suggests adequate peripheral circulation and may not directly contribute to a lower oxygen saturation reading.
C. While hypertension can potentially affect oxygen saturation through its impact on systemic vascular resistance and tissue perfusion, a blood pressure of 142/88 mm Hg alone may not significantly contribute to a lower oxygen saturation reading.

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Naxlex Comprehensive Predictor Exams

A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?

Correct Answer is A

Explanation

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

Correct Answer is D

Explanation

The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

The nurse is teaching a client about a newly prescribed medication. To confirm that the client is learning the critical information, which strategy is most important for the nurse to include during the instruction?

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The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client's attention on which focus?

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