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Patient data

Exhibits

The nurse considers the brief interaction with the client and the triage report.
Which finding(s) should the nurse investigate further? Select all that apply.

Left arm that is cool to touch

Decreased range of motion

Swelling at the site of injury

Intense pain reported by client

Oxygen saturation 95% on room air

Blood pressure of 136/90 mm Hg

Nausea and fatigue reported by client

Bone misalignment

Answer and Explanation

Correct Answer : A,B,D,G,H

A. Left arm that is cool to touch: A cool extremity can indicate impaired circulation, which is a priority concern after trauma. It may suggest compromised perfusion or neurovascular compromise, requiring immediate further investigation.

B. Decreased range of motion: The inability to move the left arm signals possible fracture, dislocation, or neurovascular impairment. Limited mobility after trauma should always be investigated to determine the extent of musculoskeletal injury.

C. Swelling at the site of injury: Swelling is expected following trauma and does not necessarily indicate a complication. While it should be monitored, it is not as urgent to investigate further compared with circulation or alignment changes.

D. Intense pain reported by client: Severe, constant pain out of proportion to the injury raises concern for complications such as compartment syndrome, fracture, or vascular compromise. This finding requires prompt further assessment and intervention.

E. Oxygen saturation 95% on room air: Although slightly lower than ideal, this level is still acceptable in an older adult and not immediately alarming. It does not require urgent further investigation compared to other more critical findings.

F. Blood pressure of 136/90 mm Hg: This blood pressure indicates mild hypertension but is not an acute concern in the setting of trauma. It does not require urgent investigation at this point.

G. Nausea and fatigue reported by client: These symptoms may suggest a head injury, concussion, or internal response to trauma. Given the reported head impact, these findings warrant further neurological evaluation.

H. Bone misalignment: Visible misalignment strongly suggests fracture or dislocation. This finding must be investigated further to confirm the diagnosis and prevent neurovascular complications.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Ensure that the restraints are snug against the client's wrists: Restraints should be snug enough to prevent injury but not so tight as to impair circulation. However, this does not address the safety concern related to the type of knot used.

B. Move the ties so the restraints are secured to the side rails: Restraints should never be tied to the side rails because this can cause injury if the rail moves or the client attempts to climb over it.

C. Ensure that the knot can be quickly released: Using a quick-release knot, such as a half bow or slip knot, is essential to ensure the nurse can rapidly remove the restraints in an emergency, such as sudden respiratory distress or circulatory compromise.

D. Tie the knot with a double turn or square knot: Square knots are secure but not quick to release. In contrast, safety guidelines recommend quick-release knots for client restraints to allow for prompt intervention.

A. Pasta with fish and an orange. B. Canned ham and green beans. C. Steak and baked potato with butter and cheese topping. D. Chicken, yams, pinto beans and pecans.

Correct Answer is A

Explanation

A. Pasta with fish and an orange: This is the best option because fish provides high-quality protein in moderation, pasta is low in potassium and phosphorus, and an orange provides vitamin C. While oranges contain potassium, a single serving can usually fit within dietary allowances if monitored.

B. Canned ham and green beans: Canned ham is high in sodium and phosphorus additives, both of which are harmful in CKD as they worsen fluid retention and bone-mineral imbalance.

C. Steak and baked potato with butter and cheese topping: Steak is a high-protein food that can increase uremic toxins, and baked potatoes are very high in potassium. The cheese topping adds extra phosphorus, making this meal unsafe for CKD clients.

D. Chicken, yams, pinto beans and pecans: While chicken is acceptable protein, yams and pinto beans are high in potassium, and pecans add excess phosphorus. This combination would increase the risk of electrolyte imbalance in CKD.

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Patient data Exhibits The nurse considers the brief interaction with the client and the triage report. Which finding(s) should the nurse investigate further? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Before leaving the room of a client who is confused, the nurse observes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. Which action should the nurse take before leaving the room?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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Patient data

Exhibits

The nurse considers the brief interaction with the client and the triage report.
Which finding(s) should the nurse investigate further? Select all that apply.