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 {"dropdown-group-1":"A"}
Explanation
A. Opioid analgesics: The client reports severe, sharp, stabbing pain with breathing and movement due to multiple rib fractures. Opioids are effective for managing moderate to severe pain, allowing the client to breathe deeply, cough effectively, and reduce the risk of complications such as atelectasis or pneumonia.
B. Antibiotics: There is no evidence of infection in this client’s presentation. Antibiotics are not indicated for pain management related to rib fractures or atelectasis without infection.
C. Antacids: Antacids are used to treat gastrointestinal upset or acid-related conditions. They do not address musculoskeletal pain or improve respiratory function in rib fractures.
D. Bronchodilators: Bronchodilators relieve airway constriction in conditions like asthma or COPD. This client’s shallow breathing is due to pain, not bronchospasm, so bronchodilators are not appropriate.
E. Antihypertensives: While the client has slightly elevated blood pressure, antihypertensives do not relieve pain or improve respiratory effort, making them irrelevant for the acute management of rib fracture–related symptoms.
Correct Answer is ["A","D","E"]
Explanation
A. Thirst: Recurrent yeast infections in adolescents may indicate underlying hyperglycemia, as excessive glucose in the urine promotes fungal growth. Thirst is a classic symptom of diabetes mellitus and should be assessed.
B. Increased appetite: While diabetes can sometimes cause polyphagia, it is less specific than other signs such as thirst, urinary frequency, and tachycardia. It may not be present in every case and is not a primary screening indicator.
C. Heat intolerance: Heat intolerance is more commonly associated with hyperthyroidism, not recurrent yeast infections. Assessing for this symptom is not directly relevant to evaluating potential diabetes in this adolescent.
D. Tachycardia: Elevated heart rate can occur with dehydration caused by hyperglycemia and osmotic diuresis. Tachycardia may be an important clinical clue in assessing for undiagnosed diabetes.
E. Urinary frequency: Polyuria is a hallmark symptom of hyperglycemia and diabetes mellitus. Recurrent yeast infections may prompt assessment for urinary frequency as part of the screening for possible diabetes.
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