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: This is correct because performing a bedside pregnancy test is the intervention that should be implemented immediately by the nurse. This is to confirm or rule out pregnancy and inform the surgical team of any possible risks or complications that may affect the client or the fetus.

Choice B reason: This is incorrect because continuing with surgery as scheduled is not an appropriate intervention without verifying the pregnancy status of the client. Surgery may pose serious threats to both maternal and fetal health, such as bleeding, infection, anesthesia complications, or miscarriage.

Choice C reason: This is incorrect because calculating gestation from last menstrual cycle is not an accurate or reliable method of determining pregnancy. The menstrual cycle can vary widely among women and may be affected by various factors such as stress, illness, or medication.

Choice D reason: This is incorrect because notifying the surgical team to cancel the surgery is not a necessary intervention unless pregnancy is confirmed. Appendicitis is a medical emergency that requires prompt surgical treatment to prevent rupture, peritonitis, or sepsis.

A. The humoral immune response lacks B cells that form antibodies and opportunistic infections result. B. Inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophages. C. Bone marrow suppression of white blood cells causes insufficient cells to phagocytize organisms. D. Exposure to multiple environmental infectious agents overburdens the immune system until it fails.

Correct Answer is B

Explanation

Choice A reason: This is incorrect because the humoral immune response involves B cells that produce antibodies against specific antigens. However, AIDS affects the cellular immune response, which involves T cells that activate other immune cells and directly kill infected cells.

Choice B reason: This is correct because AIDS is caused by human immunodeficiency virus (HIV), which infects and destroys CD4+ T cells, also known as helper T cells. These cells are essential for initiating and regulating both humoral and cellular immunity. Without enough CD4+ T cells, the body cannot mount an effective response against pathogens, especially opportunistic infections that take advantage of a weakened immune system.

Choice C reason: This is incorrect because bone marrow suppression of white blood cells is not a direct consequence of AIDS. However, some drugs used to treat AIDS, such as zidovudine, may cause bone marrow suppression as a side effect.

Choice D reason: This is incorrect because exposure to multiple environmental infectious agents does not cause AIDS. However, people with AIDS are more susceptible to infections from various sources due to their impaired immune system.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

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?

The nurse is caring for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. Which is the best initial nursing action?

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.)

A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. The client asks the nurse for an alternative way to manage sleep apnea. Which recommendation should the nurse provide?

Exhibits The triage nurse does a rapid assessment of the client. Which data indicates the client is in need of immediate health interventions?

The healthcare provider prescribes 1 liter of 0.9% sodium chloride, USP intravenously (IV) to be infused over 10 hours for a client. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?

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.