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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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Assessing papillary reactions to light is important in a neurological assessment but is not the priority in this situation.

B. Measuring and recording abdominal girth is not relevant to the client's current symptoms.

C. Auscultating over the main stem bronchus is the priority action as the client's symptoms suggest potential airway compromise, possibly from inhalation injury or swelling. Early identification and management of airway issues are critical in burn patients.

D. Determining the time of last oral intake is part of a comprehensive assessment but is not the immediate priority when airway compromise is suspected.

A. Tell the UAP to turn off the amiodarone. B. Evaluate rhythm of client's heat rate. C. Determine regularity of peripheral pulses. D. Restart the IV infusion in another site.

Correct Answer is B

Explanation

A. The UAP should not make medication decisions; only a nurse or healthcare provider should do this after assessment.

B. The nurse should evaluate the client’s heart rhythm to determine the effectiveness of the amiodarone and to assess for any arrhythmias or side effects of the medication.

C. Checking the regularity of peripheral pulses is important but secondary to assessing the heart rhythm directly.

D. Restarting the IV infusion might be necessary if there are issues with the IV site, but the primary concern is the client's cardiac status.

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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

While the nurse is admitting a client with partial thickness burns to the upper extremities, chest, and abdomen, the client experiences difficulty swallowing. The client is drooling and anxious. Which intervention should the nurse implement first?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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.

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