Exhibits

Click to highlight the findings that would indicate the client is progressing as expected.

The nurse assesses the client. The client reports he was able to sleep through the night. The client notes continued numbness in his left arm, along with a tingling sensation, and is not able to move his fingers. The client reports mild nausea and has no desire to eat breakfast. There is a 1.18 in (3 cm) by 1.97 in (5 cm) area of blood noted on the bandage. The left arm is warm to touch. The client's left shoulder and collarbone are symmetric.

The client reports he was able to sleep through the night

The left arm is warm to touch.

The client's left shoulder and collarbone are symmetric

The client reports mild nausea and has no desire to eat breakfast

Answer and Explanation

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

The client reports he was able to sleep through the night: This indicates pain management may be effective, allowing the client to rest, which is a positive sign of progress.

The left arm is warm to touch: This suggests good circulation in the injured limb, which is crucial for healing.

The client’s left shoulder and collarbone are symmetric: Symmetry suggests that the alignment of the shoulder and collarbone is stable, which indicates no further dislocation or misalignment post-injury.

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Free Nursing Study Resources

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Respirations: Morphine is an opioid analgesic that can cause respiratory depression, so monitoring the client's respiratory status is crucial after administration.

Ice application to the shoulder: Applying ice can help reduce swelling and inflammation in the injured area. This is important for managing pain and preventing further complications, such as excessive swelling or damage to surrounding tissues.

A. Client is awake and following commands B. Blood pressure 122/85 mm Hg C. Prothombin time/International normalized ratio D. Potassium 3.1 mEq/L E. Clear breath sounds

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

Client is awake and following commands: Unrelated: This finding indicates the client's level of consciousness and responsiveness, which is not directly related to the effects of furosemide. While improving fluid status can contribute to overall well-being, this finding can be influenced by various factors unrelated to the medication.

Blood pressure 122/85 mm Hg: Therapeutic: The decrease in blood pressure indicates a positive therapeutic effect of furosemide, which is a diuretic used to reduce fluid overload and lower blood pressure in patients with heart failure. The improvement from 142/99 mm Hg to 122/85 mm Hg suggests successful fluid management.

Prothrombin time/international normalized ratio: Unrelated: This laboratory finding does not directly correlate with the administration of furosemide. It is more relevant to the patient’s anticoagulation therapy (warfarin) and is monitored separately from diuretic therapy.

Potassium 3.1 mEq/L: Non-therapeutic: This finding represents a non-therapeutic side effect of furosemide. Furosemide can cause hypokalemia (low potassium levels) due to increased urinary potassium excretion. A potassium level of 3.1 mEq/L is concerning and requires monitoring and possible potassium supplementation.

Clear breath sounds: Therapeutic: The presence of clear breath sounds indicates improved lung function and resolution of pulmonary congestion, which is a therapeutic outcome of effective diuretic therapy like furosemide. The reduction in edema and fluid overload can lead to better oxygenation and breathing efficiency.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Exhibits Review H and P, nurse's notes, laboratory results, flow sheet, and orders. Click to mark whether the assessment finding represents a therapeutic result of the furosemide administered, a non-therapeutic side-effect, or an unrelated finding. Each row must have one option selected.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

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