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Patient Data

Exhibits

Review H and P and nurse's notes.

Click to highlight which assessment finding(s) should the nurse attend to right away?

Admitted client.

Vital signs

Temperature: 96.9° F (36.1° C) internal probe via urinary catheter

Heart rate: 128 beats/minute, sinus tachycardia (ST)

Respirations: 14 breaths/minute

Patient Data

Blood pressure: 90/79 mm Hg, pulse pressure less than 40 mm Hg

Oxygen saturation: 100% on 40% fraction of inspired oxygen (FiO2)

The client's surgical dressing is clean and dry. Ecchymosis noted on the abdomen around the dressing. The client has a PIV line in the right forearm and one in the left hand. The client also has a right subclavian central venous catheter that is infusing propofol and intravenous fluids. Heart sounds are regular. The skin is pink. Capillary refill is 6 seconds. Radial pulses are equal bilaterally. Lung sounds are clear and equal bilaterally. The client has an indwelling urinary catheter in place. No urine noted. The client has no visitors at this time. The social worker is attempting to contact family members. The client opens her eyes to verbal stimuli and follows verbal commands.

Heart rate: 128 beats/minute, sinus tachycardia (ST)

Blood pressure: 90/79 mm Hg, pulse pressure less than 40 mm Hg

The client's surgical dressing is clean and dry

Ecchymosis noted on the abdomen around the dressing.

Heart sounds are regular.

Capillary refill is 6 seconds.

The client has an indwelling urinary catheter in place. No urine noted.

Answer and Explanation

The Correct Answer is ["A","B","F","G"]

Rationale for correct choices

• Heart rate 128 beats/minute, sinus tachycardia: Tachycardia signals early compensatory response to hypovolemia or hemorrhagic shock, common with abdominal trauma. Immediate attention is needed to prevent cardiovascular collapse.
• Blood pressure 90/79 mm Hg, pulse pressure less than 40 mm Hg: A narrow pulse pressure with low systolic BP suggests inadequate stroke volume and poor perfusion, consistent with ongoing internal bleeding.
• Capillary refill 6 seconds: Prolonged refill indicates impaired peripheral perfusion and circulatory compromise, reinforcing concerns of shock.
• No urine output: Absence of urine is a critical marker of inadequate renal perfusion and systemic hypoperfusion, reflecting worsening shock status.

Rationale for incorrect choices

• Temperature 96.9° F (36.1° C): Slightly low but not critical; mild hypothermia is common post-trauma and can be managed after stabilizing perfusion.
• Surgical dressing clean/dry with ecchymosis: Ecchymosis is expected after trauma and surgery, requiring monitoring but not immediate intervention.
• Heart sounds regular, lung sounds clear: No acute cardiopulmonary decompensation detected.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Assess the abdomen for bowel sounds: Monitoring bowel sounds is important during opioid therapy because morphine can cause constipation. However, this assessment does not take priority when initiating PCA therapy, as it does not immediately affect safe administration or pain control.

B. Initiate the dosage lockout mechanism on the PCA pump:The lockout mechanism is the most critical safety feature of a PCA pump. It prevents the client from administering a second dose of medication before the first dose has had time to take effect. By strictly limiting the frequency of doses (e.g., a 6-to-10-minute lockout period), the pump prevents accidental overdose and toxicity. While all the listed options are part of the nursing process, ensuring the mechanical safety of the high-alert medication delivery system is the priority during the initiation phase.

C. Instruct the client to use the medication before the pain becomes severe: Teaching about preemptive use improves pain control and prevents breakthrough pain, but this instruction is most effective after determining that the client can understand and use the PCA system appropriately.

D. Assess the client's ability to use a numeric pain scale:The nurse must ensure the client can communicate their pain level to evaluate the effectiveness of the therapy. However, this is a baseline assessment that should ideally occur before the initiation of the pump. It does not carry the same immediate safety weight as securing the pump's lockout mechanism.

A. Urinate immediately into a urinal, and the laboratory will collect the specimen every 6 hours, for the next 24 hours. B. Cleanse around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle. C. For the next 24 hours, notify nurse when the bladder is full, and the nurse will collect catheterized specimens. D. Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours.

Correct Answer is D

Explanation

A. Urinate immediately into a urinal, and the laboratory will collect the specimen every 6 hours, for the next 24 hours: Intermittent collection is not used for a 24-hour urine test; continuous collection of all urine after the start time is required to accurately measure creatinine clearance.

B. Cleanse around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle: This procedure is for a clean-catch or midstream urine specimen, not a 24-hour collection, and does not provide the total volume needed for creatinine clearance.

C. For the next 24 hours, notify nurse when the bladder is full, and the nurse will collect catheterized specimens: Catheterization is unnecessary for routine 24-hour urine collection and increases infection risk. The client can collect urine in a provided container.

D. Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours: Discarding the first void establishes the start of the collection period, and collecting all urine for the next 24 hours ensures accurate measurement of creatinine clearance.

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Patient Data

Exhibits

For each assessment finding, click to indicate whether the findings from the client's assessment are generally associated with rotator cuff injury and/or humeral fracture. Each column must have at least one response selected.

View Question and Answer

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PСА) pump?

Correct Answer is B

Explanation

The nurse plans to collect a 24 hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?

Correct Answer is D

Explanation

An older adult client is referred to a rehabilitation facility following a cerebrovascular accident (CVA).The client is aphasic with left sided paresis and is having difficulty swallowing. Which intervention is most important for the nurse to include in the client's plan of care?

Patient Data Exhibits For each assessment finding, click to indicate whether the findings from the client's assessment are generally associated with rotator cuff injury and/or humeral fracture. Each column must have at least one response selected.

A client who is receiving zidovudine reports the appearance of pinpoint, red, round spots on the skin. Which result should the nurse report to the healthcare provider (HCР)?

The nurse assesses a client being treated for Herpes zoster (shingles). Which assessment(s) should the nurse include when evaluating the effectiveness of treatment? Select all that apply.

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?