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Patient Data

Exhibits

Select the 4 assessment findings that require immediate follow up.

Severe abdominal pain in right lower quadrant

Blood pressure 115/76 mm Hg

Capillary refill 2 seconds

Radial and pedal pulses 2+1

Temperature 100.8° F (38.2° C)

Respirations 28 breaths/minute with shallow breathing

Feels anxious

Heart rate 121 beats/minute

Vomiting small amounts of green bile

Answer and Explanation

Correct Answer : A,E,F,H

A. Severe abdominal pain in the right lower quadrant: This could indicate appendicitis, a surgical emergency, or another acute abdominal condition requiring immediate intervention. The sudden onset and severe nature of pain are concerning.
B. Blood pressure 115/76 mm Hg: This is within normal limits and does not indicate immediate instability.
C. Capillary refill 2 seconds: This indicates adequate peripheral perfusion and is not an urgent concern.
D. Radial and pedal pulses 2+: Normal peripheral pulses do not require immediate follow-up.
E. Temperature 100.8° F (38.2° C): Fever suggests an inflammatory or infectious process, such as appendicitis or another intra-abdominal infection.
F. Respirations 28 breaths/minute with shallow breathing: Increased respiratory rate and shallow breathing may indicate pain-related distress or developing peritonitis, a life-threatening complication of appendicitis.
G. Feels anxious: Anxiety may be a response to pain but is not an immediate concern requiring urgent intervention.
H. Heart rate 121 beats/minute: Tachycardia could be a response to pain, infection, or developing sepsis, which requires urgent evaluation.
I. Vomiting small amounts of green bile: While bile-stained emesis can indicate an obstruction, other findings (pain, fever, tachycardia, and respiratory distress) are higher priority.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Intubation is not the first step unless the client's respiratory status continues to deteriorate despite oxygen therapy.

B. Obtaining a sputum culture may be helpful but does not address the immediate respiratory compromise.

C. A nonrebreather mask with 100% oxygen provides high-flow oxygen and is essential for a client with worsening dyspnea and low oxygen saturation.

D. A forward-leaning position may help with breathing but does not provide the necessary oxygen support in this acute situation.

A. Consult the wound care specialist to evaluate the wound. B. Cleanse the wound and discontinue the VAC system. C. Reapply the VAC system after irrigating away drainage. D. Document the wound measurements with tunneling. E. Increase the wound VAC suction to eliminate the drainage.

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

Explanation

A: Consulting a wound care specialist ensures that proper infection management is initiated, and other treatment options, such as antimicrobial therapy, are considered.

B: Discontinuing VAC therapy and cleansing the wound allows for infection control and proper evaluation of the wound's condition before resuming therapy.

C: Reapplying the VAC system without addressing the potential infection could worsen the situation by promoting further bacterial growth.

D: Documenting wound measurements is important but does not address the immediate infection, which should be the priority.

E: Increasing the suction on the VAC system is inappropriate as it may exacerbate infection or tissue damage.

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Patient Data Exhibits Select the 4 assessment findings that require immediate follow up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

When changing the client's dressing for a vacuum-assisted closure (VAC) wound therapy system, the nurse observes foul, purulent drainage. Which intervention(s) should the nurse implement? Select all that apply.

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

Explanation

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An older client with osteoarthritis reports increasing pain and stiffness in the right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes which pathology as the cause of the symptoms?

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The nurse is caring for a client who has a history of experiencing delusions. The client describes singing in a concert in the afternoon for thousands of people. Which action should the nurse take?

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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.

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Patient Data

Exhibits

Select the 4 assessment findings that require immediate follow up.