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 A
Explanation
A. Watery diarrhea is a potential sign of Clostridium difficile (C. diff) infection, a serious and common complication associated with antibiotics like linezolid.
B. Nausea and headache are side effects but are less urgent than symptoms suggesting C. diff.
C. Increased fatigue is non-specific and may be related to the infection or the medication, but it is not as immediately concerning as diarrhea.
D. Yellow-tinged sputum is typical of pneumonia and does not indicate an urgent issue related to linezolid therapy.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A","dropdown-group-3":"B"}
Explanation
The client has a history of trauma with abdominal injury (lacerations to the liver and spleen) and blood in the peritoneum, indicating significant internal bleeding.
Hypovolemia (low blood volume) occurs due to blood loss from the injured organs, leading to low blood pressure (90/79 mmHg) and tachycardia (HR 128 bpm). The low hemoglobin (9.3 g/dL) and low hematocrit (30%) are consistent with either acute blood loss or hemodilution due to intravenous fluid resuscitation, which can temporarily dilute blood components. The normal clotting times (PT 11.5 sec, PTT 64 sec) do not indicate disseminated intravascular coagulation (DIC), and there is no evidence of acidosis in the provided data.
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