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A nurse is caring for a client in the emergency department.

Exhibits here

Click to highlight the findings that indicate that the client's condition is improving. To deselect a finding, click on the finding again.

1400:

Client admitted to the medical-surgical unit at 1200 today. Alert and orientated x4, heart and lung sounds clear. Client urinating 100 mL/hour.

Client is tolerating soft diet and oral fluids. Bowel sounds are hyperactive in all 4 quadrants.

Bilateral pedal pulses 2+, Blood glucose 310 mg/dl. (74 to 106 mg/dL) 1400:

Temperature 36.8° C (98.2° F)

Pulse rate 84/min Respiratory rate 16/min

Blood pressure 106/76 mm Hg Oxygen saturation 96% on room air

Alert and orientated x4

Heart and lung sounds clear

Client urinating 100 mL/hour

Client is tolerating soft diet and oral fluids

Bilateral pedal pulses 2+

Temperature 36.8° C (98.2° F)

Pulse rate 84/min

Respiratory rate 16/min

Blood pressure 106/76 mm Hg

Oxygen saturation 96% on room air

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F","G","H","I","J"]

The client's condition shows signs of improvement as indicated by several findings. The blood glucose level has decreased from 468 mg/dL to 310 mg/dL, which, although still above the normal range, is a significant improvement. The pulse rate has normalized from 110/min to 84/min, and the blood pressure has improved from 96/65 mm Hg to 106/76 mm Hg, indicating better cardiovascular stability. The

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. While wound infection prevention is important, the elastic bandage primarily addresses edema control.
B. Maintaining an elastic bandage around the residual limb helps to compress soft tissues and minimize edema, promoting healing and aiding in the shaping of the residual limb for future prosthesis fitting.
C. The purpose of the elastic bandage is not related to preventing the client from seeing the surgical site.
D. The elastic bandage is not primarily used to secure sutures; its main purpose is edema control.

A. Instruct the client to sit on a rubber ring when seated in a chair. B. Raise the head of the client's bed to a 90° angle. C. Use moisturizing lotion while massaging the client's bony prominences. D. Place pillows between the client's knees when in a side-lying position.

Correct Answer is D

Explanation

A) Instructing the client to sit on a rubber ring may provide comfort for those with hemorrhoids or perineal discomfort but is not directly related to managing hemiplegia.
B) Raising the head of the client's bed to a 90° angle may be uncomfortable and may not address the specific needs related to hemiplegia.
C) Using moisturizing lotion while massaging the client's bony prominences is important for skin integrity but does not directly address the positioning needs of a client with hemiplegia.
D) Placing pillows between the client's knees when in a side-lying position helps maintain proper alignment, prevents pressure ulcers, and promotes comfort for the client with hemiplegia.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. Which of the following is an appropriate response by the nurse?

Correct Answer is B

Explanation

A nurse is planning care for a client who has hemiplegia. Which of the following interventions should the nurse include?

Correct Answer is D

Explanation

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