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Patient Data

Exhibits

The nurse places the client on a cardiorespiratory monitor and places the nasal cannula on the client. The nurse then completes an assessment and documents it in the chart.

For each body system, click to specify the assessment findings that indicates hypoxia. At least one finding could be indicated for each system.

Body System

Assessment Finding

Neurological

Restless

Awake and alert

Anxious

Respiratory

Respiratory rate 28 breaths/minute

Oxygen Saturation 90% on room air Productive cough

Cardiovascular

Heart rate 101 beats/minute Capillary refill 4 seconds

Blood pressure 145/89 mm Hg

Restless

Awake and alert

Anxious

Respiratory rate 28 breaths/minute

Oxygen Saturation 90% on room air

Productive cough

Heart rate 101 beats/minute

Capillary refill 4 seconds

Blood pressure 145/89 mm Hg

Answer and Explanation

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

Neurological: Restlessness and anxiety can both be symptoms of hypoxia due to the brain's sensitivity to changes in oxygen levels.

Respiratory: Low oxygen saturation directly indicates hypoxia, and an increased respiratory rate can be a compensatory response to low oxygen levels.

Cardiovascular: Elevated heart rate can be a compensatory mechanism for hypoxia, and delayed capillary refill may indicate poor perfusion related to low oxygen levels.

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Correct Answer is D

Explanation

A. While the medication history can be relevant, it is not the most immediate assessment needed to address the confusion and possible infection.

B. The amount of serous drainage is important for wound assessment but does not directly address the cause of confusion.

C. Urinary output is useful for evaluating kidney function but may not be directly related to the client’s confusion and wound.

D. The white blood cell count is crucial for identifying an infection or inflammatory response, which could be related to both the confusion and the wound.

A. Tell her to consider hiring a private nurse during the postoperative convalescence. B. Suggest contacting social services to help find a respite care facility for her husband. C. Advise to have a case management evaluation of the client's home environment. D. Recommend that the client's family return to the area to help provide assistance.

Correct Answer is B

Explanation

A. Hiring a private nurse may be an option but is not the most immediate or practical solution given the client's current resources and concerns.

B. Suggesting contacting social services to find respite care is a practical and immediate solution to ensure her husband’s care while the client recovers.

C. A case management evaluation is helpful but may not address the immediate need for respite care during the client's recovery period.

D. Recommending that the family return might not be feasible or immediate, and respite care can provide the necessary support during recovery.

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Body System	Assessment Finding
Neurological	Restless Awake and alert Anxious
Respiratory	Respiratory rate 28 breaths/minute Oxygen Saturation 90% on room air Productive cough
Cardiovascular	Heart rate 101 beats/minute Capillary refill 4 seconds Blood pressure 145/89 mm Hg

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client is brought to the clinic for Increased confusion over the past three days and presents with a draining wound on the right leg. Which assessment is most important for the nurse to obtain?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

The nurse is preparing to administer a suspension ampicillin labeled, 250 mg/5 mL, to a child with impetigo. The prescription is for 500 mg four times a day. How many mL should the child receive per day? (Enter numeric value only.)

A client tells the nurse about beginning an exercise program a month ago to lose weight and improve sleep. The client states, "It still takes at least two hours to fall asleep at night." Which action should the nurse implement?

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

A client's catheter bag was left on the client's bed for a prolonged period of time, and the client develops a urinary tract infection. In evaluating the cause of the infection, what should the nurse identify as the infection reservoir?

A client with generalized anxiety disorder does not want to communicate with friends, smokes 2 to 3 packages of cigarettes a day, and describes difficulty concentrating at work. Which coping strategy should the nurse include in the plan of care?

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?