A nurse in an emergency department is caring for a client following a motor-vehicle crash.

The client’s Glasgow coma scale rating is 15.

Which of the following findings should the nurse expect

The client withdraws from pain

The client is unable to obey commands.

The client opens eyes to sound

The client is oriented times three

Answer and Explanation

The Correct Answer is D

The correct answer is choice D. The client is oriented times three.

This means that the client knows who they are, where they are, and what time it is. This indicates a high level of consciousness and a normal Glasgow coma scale (GCS) rating of 15.

Choice A is wrong because the client withdraws from pain.

This means that the client reacts to a painful stimulus by pulling away from it. This indicates a lower level of consciousness and a GCS rating of 4 for motor response.

Choice B is wrong because the client is unable to obey commands.

This means that the client does not follow simple instructions such as moving a limb or opening their eyes. This indicates a lower level of consciousness and a GCS rating of 1 or 2 for motor response.

Choice C is wrong because the client opens eyes to sound.

This means that the client does not open their eyes spontaneously, but only when they hear a loud noise. This indicates a lower level of consciousness and a GCS rating of 3 for eye opening.

The Glasgow coma scale is a clinical tool used to assess the level of consciousness of a person after a brain injury.

It consists of three tests: eye opening, verbal response, and motor response.

Each test has a score range from 1 to 6, with higher scores indicating higher levels of consciousness. The total score ranges from 3 to 15, with lower scores indicating higher risk of death.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Answer and explanation.

The correct answer is choice A. Increased Hct.

Hct stands for hematocrit, which is the percentage of red blood cells (RBCs) in the blood.

A client who received 2 units of packed RBCs should have an increased Hct because they have more RBCs in their blood volume. The normal range for Hct is 38% to 50% for males and 36% to 44% for females.

Choice B is wrong because decreased Hgb means decreased hemoglobin, which is the protein that carries oxygen in the RBCs.

A client who received 2 units of packed RBCs should have an increased Hgb because they have more hemoglobin in their blood. The normal range for Hgb is 13.5 to 17.5 g/dL for males and 12 to 15.5 g/dL for females.

Choice C is wrong because increased platelets means increased thrombocytes, which are the cells that help with blood clotting.

A client who received 2 units of packed RBCs should not have an increased platelet count because they did not receive platelets in the transfusion. The normal range for platelets is 150,000 to 400,000/mm^3.

Choice D is wrong because decreased WBC count means decreased leukocytes, which are the cells that fight infection and inflammation.

A client who received 2 units of packed RBCs should not have a decreased WBC count because they did not receive WBCs in the transfusion. The normal range for WBC count is 4,500 to 11,000/mm^3.

A. Replace the NG tube. B. Provide oral hygiene care. C. Administer an antiemetic D. Evaluate functioning of the suction device

Correct Answer is D

Explanation

The correct answer is d. Evaluate functioning of the suction device.

Choice D rationale:

Prompt assessment of the suction device is crucial to determine if it's functioning properly.If the suction is inadequate,it can lead to gastric contents accumulating and potentially causing vomiting.
Assessing the suction device first allows for timely interventionif it's not working correctly,preventing further complications and discomfort for the client.

Choice A rationale:

Replacing the NG tube might be necessary if it's dislodged or blocked, but it shouldn't be the immediate action.
Evaluating the suction device first can help determine if the NG tube itself is the issue or if the problem lies with the suction.

Choice B rationale:

Providing oral hygiene care is important for comfort and to prevent aspiration, but it's not the priority intervention in this situation.
Addressing the cause of the vomiting, which could be related to suction malfunction, takes precedence.

Choice C rationale:

Administering an antiemetic might be helpful to control nausea and vomiting, but it doesn't address the underlying cause.
Evaluating the suction device first is essential to ensure proper gastric decompression and prevent further vomiting episodes.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse in an emergency department is caring for a client following a motor-vehicle crash. The client’s Glasgow coma scale rating is 15. Which of the following findings should the nurse expect

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory data of a client who received 2 units of packed RBCs. Which of the following laboratory findings should the nurse expect following the transfusion?

Correct Answer is A

Explanation

A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actions should the nurse perform first?

Correct Answer is D

Explanation

A nurse is teaching a newly licensed nurse about caring for clients in the emergency department. Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?

A charge nurse is observing a conflict between two nurses who both insist that the charge nurse favors the other when making assignments. Which of the following conflict-resolution strategies should the charge nurse use?

A nurse is caring for a client who reports a headache and has a history of a peptic ulcer. Which of the following medications should the nurse administer?

A nurse is reporting a client’s laboratory tests to the provider to obtain a prescription for the client’s daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?

A nurse in an emergency department is caring for a client. Exhibits The nurse is providing teaching to the client about self-care. Select the 3 statements the nurse should include in the teaching.

A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate the effectiveness of the procedure?

A nurse is assisting with food selection for a client who follows kosher dietary traditions. Which of the following food choices should the nurse include on the client’s food tray?

A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?

A nurse in an emergency department is caring for a client following a motor-vehicle crash.

The client’s Glasgow coma scale rating is 15.

Which of the following findings should the nurse expect