Patient Data
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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Use electric heating pad when pain is at its worse: Heat can help relieve stiffness in arthritis, but during acute gout flares, applying heat may exacerbate inflammation. Cold therapy is generally recommended during severe joint pain episodes.
B. Increase fluid intake to 2000 mL per day: Adequate hydration helps prevent uric acid crystal formation, which can reduce the frequency and severity of gout attacks. Encouraging increased fluid intake is an important part of long-term management in clients with gouty arthritis.
C. Exercise daily for at least 30 minutes: While regular exercise supports weight loss and overall joint health, exercising during an acute flare can worsen pain and potentially injure the affected joint. Activity should be resumed gradually once inflammation subsides.
D. Eat high protein foods to achieve ideal body weight: High-protein diets, especially those rich in purines (e.g., red meat, organ meats), can exacerbate gout. Discharge teaching should focus on balanced nutrition with attention to foods that minimize uric acid levels.
Correct Answer is D
Explanation
A. Palpate flank area: Flank assessment may help detect kidney tenderness or infection but is not the primary focus for routine suprapubic catheter care unless complications are suspected.
B. Assess perineal area: The suprapubic catheter bypasses the perineal route, so routine perineal assessment is less critical for catheter management, though general hygiene remains important.
C. Measure abdominal girth: Abdominal girth measurement is useful for detecting ascites or abdominal distention but is not directly relevant to monitoring a suprapubic catheter.
D. Observe insertion site: Regular inspection of the catheter insertion site is essential to detect signs of infection, leakage, irritation, or improper placement. This assessment helps ensure catheter function and prevents complications, making it the priority during home visits.
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