Exhibits

Click to indicate which client goal is being met by each of the client data. Each column must have at least one response selected.

Blood pressure 112/77 mmHg

Capillary refill 2 seconds

pH 7.40

PaCO2 42 mmHg

Surgical dressing dry and intact

Pain 0 on a scale of 0 to 10

Temperature 98.1 oF (27.4 oC)

Answer and Explanation

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

Blood pressure 112/77 mmHg: Indicates adequate perfusion and stabilized blood pressure, which is a sign of successful hypovolemia management after trauma and fluid resuscitation.

Capillary refill 2 seconds: A normal capillary refill time suggests that peripheral circulation is stable, which helps in managing hypovolemia and maintaining adequate tissue perfusion.

pH 7.40: A normal pH supports the concept of ventilation support being effective and adequate. A normal pH indicates appropriate respiratory function and acid-base balance.

PaCO2 42 mmHg: A normal PaCO2 suggests that the client’s ventilation is adequate and CO2 is being eliminated appropriately, which is part of ventilation support.

Surgical dressing dry and intact: This observation indicates that there is no significant infection risk at the incision site. Keeping surgical dressings dry and intact helps prevent infection.

Pain 0 on a scale of 0 to 10: The client reports no pain, which indicates effective pain and anxiety control, providing comfort and minimizing stress.

Temperature 98.1°F (36.7°C): A normal body temperature indicates that there is no active infection or fever, supporting the goal of infection prevention.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["C","D","E"]

Explanation

A. Reports of pain: While pain is a common complaint during labor, especially before the epidural takes effect or if the anesthesia is wearing off, this is not an immediate priority compared to other life-threatening complications like hypotension or fetal decelerations. It can be addressed once the more urgent issues are managed.

B. Nausea: Nausea may occur with epidural anesthesia, often due to hypotension, but it is not as urgent as respiratory distress, hypotension, or fetal decelerations. It can be managed after addressing the more critical symptoms.

C. Difficulty breathing: Difficulty breathing can be an indication of a high epidural block, which can affect the respiratory muscles. This is a serious sign that requires immediate intervention to assess and potentially correct the epidural anesthesia level.

D. Hypotension: Epidural anesthesia can cause hypotension due to sympathetic blockade. Low blood pressure can reduce uteroplacental perfusion and compromise fetal oxygenation, requiring prompt intervention with fluid boluses and/or vasopressors to support maternal and fetal circulation.

E. Fetal decelerations: Fetal heart rate decelerations, particularly late or variable decelerations, may indicate fetal distress, potentially caused by maternal hypotension, uteroplacental insufficiency, or cord compression. These should be promptly assessed and addressed to optimize fetal well-being.

F. Dizziness: Dizziness is often a result of epidural anesthesia-induced hypotension and is an early sign that should be assessed. However, it is not as immediately critical as difficulty breathing or fetal heart rate decelerations and should be addressed once the more urgent concerns are managed.

A. Encourage the use of assistive feeding devices. B. Demonstrate use of a tucked-chin position while eating. C. Assist the client to lie down and turn to the side. D. Recommend the use of supplemental liquid feedings.

Correct Answer is B

Explanation

A: Assistive feeding devices may help, but they do not directly address the risk of aspiration. Improving swallowing mechanics is more immediately beneficial.

B: The tucked-chin position helps protect the airway by improving swallowing coordination and reducing the risk of aspiration during meals. It is a simple technique that can significantly help clients with swallowing difficulties.

C: Lying down can increase the risk of aspiration by allowing food to enter the airway more easily.

D: Supplemental liquid feedings may be necessary for some ALS patients, but addressing the client’s swallowing technique during meals should take priority to prevent aspiration.

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Exhibits Click to indicate which client goal is being met by each of the client data. Each column must have at least one response selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Review H and P, nurse's notes, laboratory results, flow sheet, and prescriptions. Select the 3 findings that would require immediate action from the nurse while the laboring mother is receiving an epidural anesthesia.

Correct Answer is ["C","D","E"]

Explanation

The home health nurse makes a home visit to a client with amyotrophic lateral sclerosis (ALS). The client is sitting upright while feeding themself and coughs frequently during the meal. Which action should the nurse implement?

Correct Answer is B

Explanation

A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

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Exhibits Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. The nurse recognizes that the client has dropdownas evidenced by dropdownanddropdown.

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Exhibits

Click to indicate which client goal is being met by each of the client data. Each column must have at least one response selected.