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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 A

Explanation

A. A client who is one day postoperative for a laparoscopic cholecystectomy is typically stable and requires less complex care, which is appropriate for a practical nurse to manage under the supervision of the RN.

B. A client with alcoholism, cirrhosis, and hepatic encephalopathy requires more complex care and assessment, which should be handled by the RN.

C. A client scheduled for a foot amputation due to diabetes complications likely requires ongoing assessment and care coordination that is better suited for an RN.

D. A client who is one day postoperative with a colostomy for colon cancer may have more complicated care needs related to the colostomy, making this more appropriate for the RN.

Correct Answer is ["0.75"]

Explanation

Desired dose: 0.1875 mg

Concentration of the reconstituted solution: 0.25 mg/mL

Volume to administer:

Desired dose / Concentration = 0.1875 mg / 0.25 mg/mL = 0.75 mL

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

Correct Answer is A

Explanation

Correct Answer is ["0.75"]

Explanation

A client with deep vein thrombosis (DVT) is receiving a continuous heparin IV infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse implement? Select all that apply.

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The nurse is caring for a client who has a history of experiencing delusions. The client describes singing in a concert in the afternoon for thousands of people. Which action should the nurse take?

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

Exhibits Review H and P, nurse's notes, laboratory values, flow sheet, and prescriptions. Drag from the Word Choices to complete the sentence. The client demonstrates effective epidural anesthesia by dropdown, dropdown, and dropdown.