Patient Data

The nurse is reviewing the assessment findings, laboratory data, and diagnostic results to consider the client's condition. Choose the most likely options for the information missing from the statement by selecting from the lists of options provided.

The nurse recognizes the client is most likely experiencing
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B"}

Rationale:

• Systemic inflammatory response syndrome (SIRS): The client presents with fever (101.2° F), tachycardia (126 beats/min), tachypnea (22 breaths/min), and leukocytosis (WBC 20,000/mm³), all of which meet the classic criteria for SIRS. Confusion and recent postoperative status increase suspicion for an infectious trigger. The right knee surgical site shows redness, swelling, and tenderness, suggesting a potential source of infection.

• Transient ischemic attack (TIA): A TIA typically presents with sudden, focal neurological deficits such as weakness, facial droop, or speech disturbances that resolve within 24 hours. While the client is confused, there are no focal deficits reported, and the altered mental status is more likely due to systemic inflammation or infection rather than a cerebral ischemic event. TIA does not explain fever, leukocytosis, or tachycardia.

• Pneumonia: Although the client has mild hypoxia, chest x-ray shows no infiltrates, and lung sounds are diminished but clear. There are no respiratory secretions or cough noted. While infection is suspected at the surgical site, the lungs are not the primary source. Pneumonia does not fully account for the systemic inflammatory response signs observed.

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Correct Answer is B

Explanation

Rationale:
A. A Yankauer suction: This rigid suction device is used for clearing oral secretions in clients who are spontaneously breathing. While useful, it does not provide immediate ventilatory support for a mechanically ventilated or suddenly apneic client.

B. A bag valve mask (BVM): A BVM is essential at the bedside for any intubated or ventilated client. It allows the nurse to manually ventilate the client in case of ventilator failure, accidental extubation, or acute respiratory compromise, ensuring rapid oxygenation and ventilation.

C. The crash cart: A crash cart contains emergency medications and defibrillation equipment. While important for code situations, it is not specific to immediate ventilatory support at the bedside and may be located nearby rather than directly at the client’s side.

D. A tracheostomy set: A tracheostomy set is required for clients with established tracheostomies or anticipated need for surgical airway access. For a postoperative client with an endotracheal tube, immediate ventilatory support is more effectively provided by a BVM, making it the priority equipment.

A. Serum osmolality B. Calcium C. Creatinine D. White blood cell count E. Glucose F. Carbon dioxide

Correct Answer is ["A","C","D","E"]

Explanation

Rationale:
A. Serum osmolality: Monitoring serum osmolality is critical in clients with elevated ICP or neurological injury. Abnormal osmolality can indicate fluid imbalance, which affects cerebral edema and intracranial pressure, guiding fluid management and hyperosmolar therapy if needed.

B. Calcium: While important for overall metabolic and cardiac function, calcium levels do not directly impact acute cerebral perfusion or ICP in this scenario. It is not a priority laboratory value for immediate neurological management.

C. Creatinine: Kidney function must be monitored because impaired renal function affects fluid and electrolyte management, especially with IV therapy and potential osmotic diuretics used to control ICP. Elevated creatinine may alter medication dosing and fluid strategy.

D. White blood cell count: An elevated or decreasing WBC count can indicate infection or sepsis, which can exacerbate cerebral edema or complicate recovery. Infection control is vital in neurosurgical clients with central lines and invasive procedures.

E. Glucose: Hyperglycemia is common in acute neurological injury and can worsen neuronal damage. Maintaining glucose within normal limits supports cerebral perfusion and reduces secondary brain injury.

F. Carbon dioxide: While CO₂ levels affect cerebral blood flow, monitoring arterial blood gases is typically done separately and continuously in critical care. It is important but not one of the top four labs immediately drawn from a routine blood sample in this context.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting a postoperative surgical client to the intensive care unit (ICU) and a ventilator is prescribed. While anticipating potential complications, which equipment should the nurse place at the client's bedside?

Correct Answer is B

Explanation

Patient Data During the central line placement, the healthcare provider (HCP) gives the nurse a sample of blood to send to the laboratory. Which 4 laboratory values would be most important to monitor this client's condition?

Correct Answer is ["A","C","D","E"]

Explanation

After seven days of mechanical ventilation, an older adult client is extubated and is now receiving 50% oxygen via face mask. The client has become anxious and is beginning to hyperventilate. Which intervention is most important for the nurse to implement?

Which intervention(s) should the nurse include in the plan of care (POC) for a client who is admitted with hyperosmolar hyperglycemic syndrome (HHS)? Select all that apply.

A client is admitted to the intensive care unit (ICU) with increasing shortness of breath due to a pulmonary embolism (PE). Which finding should the nurse immediately report to the healthcare provider (HCP)? Reference Range: Central venous pressure (CVP) [2 to 14 cm H2O]

A client diagnosed with pancreatitis reports severe epigastric pain. After administering a narcotic analgesic, the client insists on sitting up and leaning forward. Which action should the nurse implement?

After an endotracheal intubation is performed, bilateral breath sounds can be auscultated. No epigastric gurgling can be heard, and there is an audible gurgle from the client's mouth. Which intervention should the nurse implement?

Patient Data Click to mark whether the nursing action is indicated, contraindicated, or non-urgent. Each row must have one option selected.