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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.

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Free Nursing Study Resources

Correct Answer is ["122"]

Explanation

1. Convert pounds to kilograms:

160 pounds / 2.2 pounds/kg = 72.7 kg (approximately 73 kg)

2. Calculate the total daily dose:

Total daily dose = 5 mg/kg/day * 73 kg = 365 mg/day

3. Calculate the single dose:

Since the medication is to be administered every 8 hours (three times a day), divide the total daily dose by 3:

Single dose = 365 mg/day / 3 doses = 121.67 mg/dose

4. Round to the nearest whole number:

Single dose = 122 mg

Therefore, the nurse should administer 122 mg of gentamicin with each dose.

A. Encourage sitting up and ambulation B. Monitor for bleeding once daily C. Use Incentive spirometer every 1 hour D. Promote adequate hydration E. Assess for sedation after pain medications F. Complete neurologic assessment every 2 hours G. Administer pain medication after activity

Correct Answer is ["A","C","D","E","G"]

Explanation

A. Early ambulation helps prevent complications such as atelectasis, pneumonia, and deep vein thrombosis (DVT). It also promotes intestinal motility.
B. Monitoring for bleeding should be more frequent, especially in the immediate postoperative period, rather than just once daily.
C. This helps prevent respiratory complications such as atelectasis and promotes lung expansion.
D. Adequate hydration is essential to maintain fluid balance, promote healing, and prevent complications such as urinary tract infections and constipation.
E. Monitoring for sedation is crucial to ensure that pain medications are not causing excessive drowsiness, which could impair the client's ability to participate in activities such as ambulation and use of the incentive spirometer.
F. While assessing neurological status is important, frequent neurological assessments are more relevant for clients with neurological conditions or concerns. In this case, routine assessments should be sufficient unless the client has specific neurological symptoms.
G. Administering pain medication after activity helps manage pain more effectively and encourages the client to engage in necessary postoperative activities.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An client who weighs 160 pounds receives a prescription for gentamicin 5 mg/kg/day IV in divided doses every 8 hours. How many mg should the nurse administer with each dose? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Correct Answer is ["122"]

Explanation

Exhibits The nurse is caring for the client the morning after her surgery. Click to select the 5 most important nursing interventions for postoperative client care.

Correct Answer is ["A","C","D","E","G"]

Explanation

The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?

Exhibits New data is reviewed. Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. This client is exhibiting signs of dropdown. The nurse is a mandated reporter and therefore must report the elder mistreatment todropdown.

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?

Exhibits The client has started to wake up more, opening her eyes without stimulation and looking around the room. Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.

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.

Patient Data

Exhibits

Select the 4 assessment findings that require immediate follow up.