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Review H and P and nurses’ notes.

Exhibits

Click to highlight which assessment findings should the nurse attend to right away?

Admitted client. Vital signs: heart rate 128 beats/minute, rhythm sinus tachycardia, respiratory rate 14 breaths/minute, oxygen saturation 100% on 40% fraction of inspired oxygen, temperature 96.9° F (36.1° C), blood pressure 90/79 mm Hg. Pulse pressure calculated to be less than 40 mm Hg. The client's surgical dressing is clean and dry. Ecchymosis noted on the abdomen around the dressing. The client has a peripheral intravenous 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 rate 128 beats/minute

rhythm sinus tachycardia

respiratory rate 14 breaths/minute

oxygen saturation 100% on 40% fraction of inspired oxygen

temperature 96.9° F (36.1° C)

blood pressure 90/79 mm Hg

surgical dressing is clean and dry

Ecchymosis noted on the abdomen around the dressing

Answer and Explanation

The Correct Answer is ["A","B","E","F","H"]

Heart Rate: 128 beats/min (Sinus Tachycardia): Sinus tachycardia can be a compensatory response to hypovolemia, internal bleeding, or pain. Given the liver and spleen lacerations identified on the CT scan and blood in the peritoneum, tachycardia may indicate ongoing hemorrhage or hypoperfusion.

Blood Pressure: 90/79 mmHg (Narrow Pulse Pressure): A pulse pressure of less than 40 mmHg suggests inadequate perfusion and possible hemorrhagic shock. The systolic blood pressure (90 mmHg) is at the lower limit of normal, but the diastolic pressure (79 mmHg) is elevated, which can indicate compensatory vasoconstriction due to hypovolemia. Immediate fluid resuscitation or blood transfusion may be required to prevent worsening shock.

Temperature: 96.9°F (36.1°C): Trauma clients, especially those with hemorrhage, are at risk for trauma triad of death (hypothermia, acidosis, coagulopathy) due to massive fluid shifts and blood loss. Even mild hypothermia can impair coagulation and worsen bleeding, requiring active warming measures (e.g., warm IV fluids, heated blankets).

Abdominal Ecchymosis and Hematoma: Significant bruising around the surgical dressing suggests ongoing internal bleeding or vascular injury.

Close monitoring is needed to assess for expanding hematoma, increased abdominal distension, or hemodynamic instability.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. While measuring body temperature is important for infection monitoring, it is not the primary concern after prasugrel administration.
B. Pedal edema is not a common side effect of prasugrel and does not directly relate to its adverse effects.
C. Prasugrel is an antiplatelet medication that increases the risk of bleeding. Monitoring for signs of bleeding, such as blood in the urine (hematuria), is important to assess for adverse effects.
D. Assessing skin turgor is important for hydration status but does not address bleeding risks associated with prasugrel.

A. Client's bladder. B. Catheter tubing. C. The client's bed. D. Urinary meatus.

Correct Answer is B

Explanation

A. Client's bladder: The bladder is typically sterile. Infection is most likely introduced from external sources such as the catheter or tubing.
B. Catheter tubing: The catheter and its tubing can harbor bacteria, which increases the risk of a urinary tract infection.
C. The client's bed: Although the bed should be kept clean, it is unlikely to be the direct source of infection.
D. Urinary meatus: The meatus is usually sterile, and infection is more likely to arise from the catheter or tubing.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this clients plan of care?

Correct Answer is C

Explanation

A client's catheter bag was left on the client's bed for a prolonged period of time, and the client develops a urinary tract infection (UTI). In evaluating the cause of the infection, which should the nurse identify as the infection reservoir?

Correct Answer is B

Explanation

A client with renal calculi is experiencing hematuria and reports severe flank pain. Which intervention should the nurse implement first?

The friend of a nurse who works in an acute care hospital asks the nurse to review the adult daughter's electronic medical record (EMR) to determine if she is honestly disclosing her medical condition. The nurse's reply should include which information? Select all that apply.

When changing the client's dressing for a vacuum-assisted closure (VAC) wound therapy system, the nurse observes foul, purulent drainage. Which intervention(s) should the nurse implement? Select all that apply.

The nurse is preparing to administer a formula feeding by nasogastric tube (NGT) to a 2-month-old. Which intervention should the nurse implement?

Which instruction should the nurse provide to a client who is preparing to have a cystoscopy?

A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instruction(s) should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Select all that apply.

A client with pancreatitis reports severe epigastric pain, so the nurse administers a prescribed narcotic analgesic Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement?