A nurse is caring for a 24-year-old female client in the post-operative unit following a horseback riding accident.

Exhibits
Which of the following assessment findings should the nurse attend to right away?

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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

Donning appropriate personal protective equipment (PPE), including an N95 respirator mask, face shield, gown, gloves, and shoe coverings, is crucial to protect the nurse from potential exposure to the virus during close contact with a symptomatic client.

Choice B rationale

Teaching the client to wear a mask, hand wash, and maintain social distance is essential for preventing virus spread but is secondary to protecting the healthcare provider while collecting a test sample from a symptomatic client.

Choice C rationale

Informing the client to notify others about potential exposure is an important step in contact tracing, but it does not directly protect the nurse during the specimen collection procedure.

Choice D rationale

Notifying the charge nurse about the client's need for assignment to a COVID-19 designated area is important for appropriate care and isolation but does not directly address immediate protection for the nurse during the testing procedure.

A. pH 7.36. B. Partial pressure of oxygen (PaO2) 82 mm Hg. C. Partial pressure of carbon dioxide (PaCO2) 38 mm Hg. D. Bicarbonate (HCO3-) 24 mEq/L (24 mmol/L).

Correct Answer is ["A","B","C","D"]

No explanation

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A nurse is caring for a 24-year-old female client in the post-operative unit following a horseback riding accident. Exhibits Which of the following assessment findings should the nurse attend to right away?

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Explanation

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A nurse is caring for a 24-year-old female client in the post-operative unit following a horseback riding accident.

Exhibits
Which of the following assessment findings should the nurse attend to right away?