Exhibits
Click to highlight the assessment findings that require immediate follow up by the nurse.
Client is admitted to the medical floor. She has mild subcostal retractions and is sitting in an upright position. Wheezes are noted throughout the lung fields. The client is pale. She has strong peripheral pulses that are equal bilaterally. Her heart rate is 122 beats/minute, blood pressure 134/85 mm Hg, oxygen saturation 91% on room air.
mild subcostal retractions
Wheezes are noted throughout the lung fields
The client is pale
She has strong peripheral pulses that are equal bilaterally
oxygen saturation 91% on room air
heart rate is 122 beats/minute
The Correct Answer is ["A","B","C","E","F"]
Client is admitted to the medical floor. She has mild subcostal retractions and is sitting in an upright position. Wheezes are noted throughout the lung fields. The client is pale. She has strong peripheral pulses that are equal bilaterally. Her heart rate is 122 beats/minute, blood pressure 134/85 mm Hg, oxygen saturation 91% on room air.
Rationale:
An oxygen saturation level of 91% indicates hypoxemia, which is concerning and requires immediate intervention. Normal oxygen saturation levels should be between 95% and 100%. The nurse should assess the client further and consider supplemental oxygen or other interventions to improve oxygenation.
Wheezing suggests bronchoconstriction, indicating that the client is experiencing significant respiratory distress. Given her history of asthma and the ineffectiveness of her usual albuterol dose, further assessment and potential escalation of treatment (such as systemic corticosteroids or nebulized medications) are warranted.
Pallor can be a sign of decreased perfusion or oxygenation and may indicate a worsening respiratory condition. This finding requires further evaluation of vital signs and potential interventions to address the underlying cause.
Tachycardia (elevated heart rate) may indicate stress or inadequate oxygenation, especially in the context of respiratory distress. The nurse should monitor the client's cardiovascular status closely and consider the need for interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Reporting an increase in the white blood cell count is important for monitoring infection but does not directly prevent recurrence of MRSA in the wound.
B. Instructing the family to adhere to contact precautions is critical in preventing the transmission of MRSA and protecting the postoperative wound from infection.
C. Changing the surgical dressing when soiled is important for wound care but is not as preventive as ensuring contact precautions are followed by all caregivers.
D. Wearing a face mask while performing wound care is not a standard requirement for MRSA prevention in surgical wounds, as MRSA is primarily transmitted via contact.
Correct Answer is A
Explanation
A. The right leg being externally rotated and shorter than the left is a classic sign of a hip fracture and should be reported for further evaluation and management.
B. The ability to wiggle the right toes indicates that some nerve function is intact and is not a concerning finding in this context.
C. A warm left lower extremity could indicate circulation but is not as urgent as a potential fracture finding.
D. Strong bilateral pedal pulses are a positive sign, suggesting adequate blood flow, and do not require immediate reporting.
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