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 C
Explanation
A. Relying solely on the client’s statement is insufficient for determining fall risk. A more comprehensive assessment is needed.
B. Advanced age alone does not automatically categorize a client as high risk for falls. A complete assessment should be used to evaluate risk.
C. A thorough assessment, including a fall risk survey, is essential to accurately determine the client’s risk for falling. The fact that the client has never fallen does not automatically categorize them as low risk.
D. Informing the client that falls occur more often in the hospital than at home does not address the need for an individualized risk assessment.
Correct Answer is D
Explanation
A. Provide the client written information about end-of-life care.
Although educating patients is a fundamental nursing duty, distributing pamphlets is a task-oriented activity that does not support "continuity of care." The client may be emotionally or physically worn out at the time of transfer. It is early and lacks the essential clinical handoff between specialists to provide them documentation before developing a therapeutic relationship or comprehending their current problems.
B. Mark the chart with client's request for no heroic measures.
This document outlines the need for thorough documentation and clerical work in clinical settings, emphasizing its importance for safety by preventing undesirable outcomes. It highlights that while the act of documentation is static, the process of continuity of care is dynamic. Specifically, it notes that simply marking a chart does not adequately communicate critical information such as the client's discomfort level, medication schedule, or emotional state regarding their child.
C. Reassure the client that the client's child will be allowed to visit.
This psychosocial intervention is outstanding. This is a significant cause of worry for a parent of a small child. On the other hand, "continuity of care" describes the more comprehensive transfer of the nursing and medical plan. Until you have the whole report on the client's status and the capabilities of the unit, you cannot properly reassure the client about certain unit policies (such as kid visitation in a sterile or restricted area).
D. Obtain a detailed report from the nurse transferring the client.
This is the gold standard for Continuity of Care. A professional handoff (usually via SBAR) ensures that the receiving nurse knows exactly where the previous nurse left off.
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