Patient Data
Click to indicate which client goal is being met by each of the client data. Each column must have at least one response selected.
Temperature 98.1° F (36.7° C)
pH 7.40
Blood pressure 112/77 mm Hg
Capillary refill 2 seconds
Pain 0 on a scale of 0 to 10
Surgical dressing dry and intact
The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"C"}}
• Temperature 98.1°F (36.7°C): Afebrile status indicates that the body is not mounting a febrile response to pathogens, showing infection is being prevented postoperatively.
• pH 7.40: Normal pH reflects adequate perfusion and circulation after fluid resuscitation, suggesting hypovolemia has been managed effectively.
• Blood pressure 112/77 mm Hg: Stable blood pressure within normal range after fluid bolus demonstrates restoration of circulating volume, consistent with hypovolemia management.
• Capillary refill 2 seconds: Normal refill indicates improved tissue perfusion after fluid therapy, confirming adequate correction of hypovolemia.
• Pain 0 on a scale of 0 to 10: Absence of reported pain while sedated indicates comfort and relief of anxiety, showing pain control is being achieved.
• Surgical dressing dry and intact: A clean, dry surgical site without drainage supports the goal of preventing infection after abdominal trauma surgery.
• PaCO2 42 mm Hg: PaCO 2 of 42 mm Hg is within the normal range (35−45 mm Hg) and indicates effective ventilation. This is primarily an ABC or respiratory goal, not directly related to the three listed goals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Before going to bed: Bedtime glucose checks may be recommended for some clients, especially those on insulin, but this timing is individualized. It is not universally required for every client with diabetes.
B. During acute illness: Any client with diabetes, regardless of age or type, should monitor glucose closely during acute illness. Illness can cause stress-induced hyperglycemia or unpredictable fluctuations, requiring more frequent testing to guide management.
C. Prior to exercising: Checking glucose before exercise is important for clients at risk of hypoglycemia, especially those using insulin or certain oral agents. However, this is not necessary for all clients, particularly those with type 2 diabetes controlled by diet alone.
D. Immediately after meals: Postprandial monitoring is useful in some cases to evaluate mealtime insulin effectiveness or dietary impact, but it is not universally recommended for every diabetic client. Its use depends on individualized treatment plans.
Correct Answer is B
Explanation
A. Initiate passive range of motion exercises: While important for preventing contractures and maintaining mobility in the affected limbs, this intervention does not address the immediate risk associated with dysphagia, such as aspiration.
B. Facilitate a consultation for speech therapy: Speech therapy can assess and provide interventions for both communication deficits and swallowing difficulties. Addressing dysphagia is critical to prevent aspiration, choking, and malnutrition, making this the highest-priority intervention.
C. Use pictures and gestures to communicate: Supporting communication is important for client engagement and safety, but it does not directly address the physiological risks associated with swallowing difficulties.
D. Arrange for daily home care assistance: Planning for post-discharge care is necessary for long-term support, but immediate assessment and intervention for dysphagia take priority to ensure the client’s safety during the current hospitalization.
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