A nurse is assisting with the care of a client
Pedal pulses
Heart rate
Oxygen saturation
Blood pressure
Abdominal dressing
Breath sounds
Correct Answer : B,D,E
Rationale:
• Heart rate of 110/min indicates tachycardia, which can be an early sign of hypovolemia, sepsis, or pain and should be followed up due to the recent report of a "popping" sound and increased drainage.
• Abdominal dressing now has a large amount of serosanguinous drainage, suggesting possible wound dehiscence or evisceration, which is a surgical emergency requiring prompt evaluation.
• Blood pressure of 98/50 mm Hg indicates hypotension, which, along with tachycardia and fever, suggests potential sepsis or internal fluid loss and needs immediate intervention.
• Pedal pulses are 2+, which is within normal limits and unchanged from Day 1, indicating adequate peripheral perfusion at present.
• Oxygen saturation at 95% on room air is within normal limits and not significantly changed from previous levels, requiring no urgent action.
• Breath sounds are still clear and present bilaterally, indicating no respiratory compromise or pulmonary complication at this time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. "This medication prevents your baby from developing jaundice.": Phytonadione (vitamin K) does not play a role in bilirubin metabolism or the prevention of jaundice. Jaundice results from immature liver function and increased bilirubin levels, unrelated to vitamin K activity.
B. "This medication prevents your baby from developing bleeding problems.": Phytonadione is given to newborns to promote clotting factor synthesis and reduce the risk of hemorrhagic disease of the newborn. Newborns have low vitamin K stores at birth, making supplementation essential for preventing bleeding disorders.
C. "This medication enhances regulation of your baby's temperature.": Thermoregulation in newborns is managed by external warming and metabolic processes, not by vitamin K. Phytonadione has no impact on temperature control or thermal stability.
D. "This medication enhances your baby's immune response.": Vitamin K does not affect immune function. Its role is in coagulation, not immune system development or enhancement, and therefore does not influence infection prevention or immune strength.
Correct Answer is C
Explanation
Rationale:
A. Thoracotomy set: A thoracotomy set is used for emergency chest procedures, such as to relieve a pneumothorax or drain the pleural space. It is not relevant to a thyroidectomy, which involves the neck and airway rather than the thoracic cavity.
B. Vacuum assisted wound device: A vacuum-assisted wound device is used for chronic or large open wounds requiring negative pressure therapy. It is not indicated for fresh surgical incisions or preventive airway management following thyroid surgery.
C. Tracheostomy kit: A tracheostomy kit should be readily available at the bedside following thyroid surgery because of the risk of airway obstruction from swelling, bleeding, or damage to the recurrent laryngeal nerve. Immediate airway access may be needed in case of respiratory distress.
D. Tuning fork: A tuning fork is used in auditory and vibration assessments, such as during Rinne and Weber tests. It has no relevance to the immediate post-operative care of a client undergoing a thyroidectomy.
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