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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Free Nursing Study Resources

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

Explanation

A. Anti-cyclic citrullinated peptide (anti-CCP) antibodies are highly specific for rheumatoid arthritis (RA). A positive result supports the diagnosis of RA.
B. C-reactive protein is an inflammatory marker that is elevated in active RA, reflecting inflammation in the body.
C. Sedimentation rate (ESR) is also an inflammatory marker and is often elevated in RA, indicating active inflammation.
D. D-Dimer is a test that assesses for the presence of clot formation and breakdown. It is not used for diagnosing RA.
E. White blood cell count may be slightly elevated in RA due to inflammation, but it is not specific for RA and is less helpful in the diagnosis compared to the other tests.

A. Assess the client's pain B. Increase the propofol infusion C. Notify the social worker the client is awake. D. Have the client sign consent forms for procedures already performed E. Consider extubating the client F. Determine the client's decision-making ability G. Decrease the noise and light stimuli in the room as much as possible H. Explain all procedures

Correct Answer is ["A","F","G","H"]

Explanation

A. Assess the client's pain: The client has experienced significant trauma, undergone surgery, and may be in pain or discomfort as she regains consciousness. Pain assessment is crucial for adequate pain management and to prevent agitation or hemodynamic instability.
B. Increase the propofol infusion: Increasing sedation should not be the first response. Instead, assess the client’s pain and agitation, and if necessary, adjust sedation based on clinical need and provider recommendations.
C. Notify the social worker the client is awake: A social worker may be involved in care planning, but waking up does not require immediate notification.
D. Have the client sign consent forms for procedures already performed: If the client was incapacitated at the time of previous procedures, consent was likely obtained from a legal surrogate. Retroactive consent is not legally valid.
E. Consider extubating the client: The decision to extubate should be based on respiratory assessments, arterial blood gas (ABG) results, and overall stability, not just the client waking up.
F. Determine the client’s decision-making ability: As the client becomes more aware, it is important to assess cognitive function and orientation to determine if she can participate in decisions regarding her care. If the client is alert and coherent, she may be able to provide informed consent for further treatments.
G. Decrease the noise and light stimuli in the room as much as possible: Critically ill patients can become disoriented and agitated as they wake up. A calm environment helps reduce stress and delirium, improving recovery and promoting rest.
H. Explain all procedures: The client is waking up in an unfamiliar environment (intubated in the ICU), which can be frightening and disorienting. Explaining procedures provides reassurance and can help reduce anxiety and agitation.

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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

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

Explanation

Exhibits The client has started to wake up more, opening her eyes without stimulation and looking around the room. Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.

Correct Answer is ["A","F","G","H"]

Explanation

A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instruction(s) should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Select all that apply.

A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential problem has the highest priority when planning nursing care for this client?

The nurse is teaching a male adolescent recently diagnosed with type 1 diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate the effectiveness of the teaching?

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.

The nurse knows that a medication has the side effect of orthostatic hypotension. Which assessment should the nurse make before administering the medication?

Exhibits The nurse is stabilizing the client and preparing her for surgery. What goal(s) should the nurse prioritize in the care plan for the client while in the emergency department? Select all that apply.

The nurse is completing the admission assessment of a client with multiple sclerosis (MS). Which finding(s) should be reported to the healthcare provider immediately? Select all that apply.

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.