Patient Data

Exhibits

Drag from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

For Potential Conditions:

The correct answer is c) Abdominal compartment syndrome.

Choice A reason: Pneumothorax is a condition where air leaks into the pleural space, causing lung collapse and impaired gas exchange. It can cause respiratory distress, hypoxia, chest pain, and decreased breath sounds on the affected side. However, it does not cause abdominal distension, acidosis, or hyperglycemia.

Choice B reason: Pulmonary embolism is a condition where a blood clot blocks one or more pulmonary arteries, causing impaired gas exchange and reduced blood flow to the lungs. It can cause respiratory distress, hypoxia, chest pain, and tachycardia. However, it does not cause abdominal distension, acidosis, or hyperglycemia.

Choice C reason: Abdominal compartment syndrome is a condition where increased intra-abdominal pressure causes reduced blood flow to the abdominal organs and impaired diaphragm movement. It can cause respiratory distress, hypoxia, abdominal distension, acidosis, decreased urine output, and organ failure. It is a common complication of cirrhosis with ascites.

Choice D reason: Sepsis is a condition where a systemic inflammatory response to an infection causes organ dysfunction and hypoperfusion. It can cause respiratory distress, hypoxia, fever or hypothermia, tachycardia, acidosis, and hyperglycemia. However, it does not cause abdominal distension unless there is an intra-abdominal infection.

The two actions the nurse should take to address abdominal compartment syndrome are:

Prepare the client for a paracentesis: Paracentesis is a procedure where a needle or catheter is inserted into the peritoneal cavity to drain excess fluid and reduce intra-abdominal pressure.
Place an intravenous line to start fluid boluses: Fluid boluses are given to maintain adequate blood pressure and perfusion to the vital organs.

The two parameters the nurse should monitor to assess the client’s progress are:

Oxygen saturation: Oxygen saturation reflects the amount of oxygen bound to hemoglobin in the blood. It should be maintained above 90% to ensure adequate oxygen delivery to the tissues.
Urine output: Urine output reflects the function of the kidneys and the perfusion of the renal arteries. It should be maintained above 0.5 mL/kg/hour to prevent acute kidney injury and electrolyte imbalances.

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Correct Answer is A

Explanation

Choice A reason: Returning for periodic liver function studies is an important instruction for a client with gouty arthritis who is taking colchicine and indomethacin. These medications can cause liver toxicity, which can manifest as jaundice, abdominal pain, nausea, vomiting, and dark urine. The nurse should advise the client to monitor for these signs and symptoms, and to have regular blood tests to check the liver enzymes and function.

Choice B reason: Massaging joints to relax muscles and decrease pain is not a recommended instruction for a client with gouty arthritis who has acute inflammation of the right ankle and great toe. Massage can increase the blood flow and pressure to the affected joints, which can worsen the pain and swelling. The nurse should advise the client to avoid touching or moving the inflamed joints, and to apply ice packs or cold compresses to reduce the inflammation.

Choice C reason: Limiting use of mobility equipment to avoid muscle atrophy is not a necessary instruction for a client with gouty arthritis who has acute inflammation of the right ankle and great toe. Mobility equipment such as crutches, walkers, or canes can help the client to ambulate safely and comfortably, and to prevent further injury or damage to the affected joints. The nurse should encourage the client to use mobility equipment as needed, and to perform gentle range of motion exercises when the inflammation subsides.

Choice D reason: Substituting natural fruit juices for carbonated drinks is not a helpful instruction for a client with gouty arthritis who is taking colchicine and indomethacin. Fruit juices can contain high amounts of fructose, which can increase the uric acid levels in the blood and trigger gout attacks. Carbonated drinks are not a major risk factor for gout, unless they contain high-fructose corn syrup or alcohol. The nurse should advise the client to drink plenty of water, and to avoid foods and beverages that are high in purines, such as organ meats, seafood, beer, and wine.

A. Make a referral for social services at home. B. Continue to limit daily fluid intake to 500 mL. C. Begin preparing the client for discharge home. D. Recommend strict intake and output monitoring.

Correct Answer is C

Explanation

Choice A reason: A referral for social services at home is not necessary for a client with Addison's disease who has stable vital signs, adequate hydration, and good self-care knowledge.

Choice B reason: Limiting daily fluid intake to 500 mL is not appropriate for a client with Addison's disease, who is at risk of dehydration and hypotension. The client should drink fluids according to thirst and urine output.

Choice C reason: Preparing the client for discharge home is the best action for the nurse to implement, as the client has no signs of complications or deterioration from Addison's disease. The client should be able to manage the condition at home with regular follow-up and medication adherence.

Choice D reason: Strict intake and output monitoring is not required for a client with Addison's disease who has normal blood pressure, moist mucous membranes, and strong peripheral pulses. These indicate adequate fluid balance and renal function.

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Patient Data Exhibits Drag from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Correct Answer is C

Explanation

While completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she may be pregnant. The operating team is preparing to take the client to surgery. Which intervention should the nurse implement immediately?

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The nurse is providing dietary instructions for a client who is being discharged after passing a calcium oxalate renal stone. Which food should the nurse instruct the client to avoid?

Exhibits Specify which potential condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s response.

The nurse prepares a teaching plan for an adult client with metabolic syndrome. Which finding(s) should the nurse address to help the client reduce the risk for diabetes mellitus and vascular disease? (Select all that apply.)

Patient Data

Exhibits

Drag from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.