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
The Correct Answer is ["A","B"]
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"C"}
Explanation
Hemorrhaging:
The client exhibits signs of excessive vaginal bleeding, as indicated by a boggy fundus and saturated pads and sheets beneath her. The significant blood loss is concerning, especially following a 4th-degree laceration and the recent delivery.
Uterine Atony:
The fundus is noted to be boggy (soft) at multiple assessments, which is a key indicator of uterine atony. This condition is the most common cause of early postpartum hemorrhage and occurs when the uterus fails to contract effectively after delivery, leading to excessive blood loss.
Correct Answer is D
Explanation
A. Client A's oxygen saturation of 94% is within an acceptable range for someone with emphysema, and increasing oxygen may not be necessary at this time.
B. Moving Client D into an isolation room may not be necessary based solely on the elevated WBC count, which could indicate an infection but does not mandate isolation without additional symptoms.
C. Client C’s potassium level of 3.8 mEq/L is within the normal range, so there is no urgent need to add a banana.
D. Verifying that Client B has two units of packed cells available is critical due to the low postoperative hemoglobin level, indicating a need for potential transfusion.
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