A nurse is caring for a 24-year-old female client in the post-operative unit following a horseback riding accident.
Oxygen saturation of 100% on 40% oxygen
Capillary refill time of 6 seconds
Blood pressure of 90/79 mmHg with a pulse pressure of less than 40 mmHg
The client’s lack of urine output from the indwelling catheter
Correct Answer : B,C,D
Choice B rationale: Capillary refill time of 6 seconds is significantly delayed and indicates poor peripheral perfusion. This finding suggests that the client may be experiencing decreased cardiac output or hypovolemia, which requires immediate attention to improve circulation and oxygen delivery to tissues.
Choice C rationale: Blood pressure of 90/79 mmHg with a pulse pressure of less than 40 mmHg is a critical finding. The narrow pulse pressure and hypotension indicate potential hypovolemia or shock, which must be addressed urgently to stabilize the client's hemodynamic status.
Choice D rationale: The client’s lack of urine output from the indwelling catheter is concerning and indicates potential kidney dysfunction or decreased renal perfusion. Immediate intervention is necessary to assess and manage potential underlying causes, such as hypovolemia or renal injury.
Choice A rationale: Oxygen saturation of 100% on 40% oxygen is not an immediate concern. While it is important to continue monitoring oxygen levels, the client is currently receiving adequate oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Participation of community leaders in planning the program is crucial because these leaders have an in-depth understanding of the community's needs and concerns. Their involvement ensures that the program is culturally relevant and addresses the specific health disparities faced by African-American women. Additionally, community leaders can help foster trust and encourage participation from community members, making the program more effective.
Choice B rationale
While morbidity data for breast cancer in women of all races can provide valuable information on overall trends, it does not address the specific needs and challenges faced by African-American women. Focusing on the unique risks and barriers faced by this group is essential for designing an effective health promotion program.
Choice C rationale
A listing of African-American women who live in the community is useful for outreach and engagement but does not provide the essential insight needed to design a culturally sensitive and relevant program. Participation from community leaders is more effective in understanding and addressing the community's specific needs.
Choice D rationale
Technical assistance to produce a video on breast self-examination is valuable for education but is not the most important resource for designing a comprehensive health promotion program. The program must be tailored to the community's unique needs, which requires input from community leaders.
Correct Answer is D
Explanation
Choice A rationale
The client's healthcare power of attorney is important information but not the most urgent detail to report when there is a sudden change in the client's condition. Immediate clinical changes take priority.
Choice B rationale
The fall at home as the reason for admission provides background information but does not address the urgent change in the client's mental status. The primary focus should be on the sudden increase in confusion.
Choice C rationale
Currently prescribed medications are important to consider, especially if they could contribute to the client's confusion. However, the sudden change in mental status is more critical to report first.
Choice D rationale
Increasing confusion of the client is the most urgent information to report. It indicates a significant change in the client's condition that requires immediate assessment and intervention by the healthcare provider. Identifying and addressing the cause of this change is crucial to prevent further complications.
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