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)
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Petroleum jelly should not be used around the nose of a toddler receiving oxygen due to the risk of aspiration and the potential for oxygen to ignite the jelly.
B. Topical lidocaine is not appropriate for cracked lips, as it can cause numbness and possibly interfere with the child's ability to protect their airway.
C. Asking the mother is a good communication approach, but the nurse should also take immediate action to address the dryness using an appropriate lubricant.
D. Use a water-soluble lubricant on affected oral and nasal mucosa is the most appropriate intervention, as petroleum jelly can be harmful if inhaled, and a water-soluble lubricant is safer for use in the nasal and oral areas, especially in young children.
Correct Answer is ["0.7"]
Explanation
1. Convert pounds to kilograms:
22 pounds / 2.2 pounds/kg = 10 kg
2. Calculate the total daily dose:
Total daily dose = 50 mg/kg/day * 10 kg = 500 mg/day
3. Calculate the single dose:
Since the medication is to be administered every 8 hours (three times a day), divide the total daily dose by 3:
Single dose = 500 mg/day / 3 doses = 166.67 mg/dose
4. Calculate the volume to administer:
The concentration of the medication is 250 mg/5 mL.
To find the volume, divide the desired dose (166.67 mg) by the concentration (250 mg/5 mL):
Volume = 166.67 mg / (250 mg/5 mL) = 0.67 mL
Therefore, the nurse should administer 0.7 mL of amoxicillin suspension with each dose.
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