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Exhibits

Review H and P and nurse's notes.

Click to highlight which assessment findings should the nurse attend to right away?

Admitted client. Vital signs: heart rate 128 beats/minute, rhythm sinus tachycardia, respiratory rate 14 breaths/minute, oxygen saturation 100% on 40% fraction of inspired oxygen, temperature 96.9° F (36.1° C), blood pressure 90/79 mm Hg. Pulse pressure calculated to be less than 40 mm Hg. The client's surgical dressing is clean and dry. Ecchymosis noted on the abdomen around the dressing. The client has a peripheral intravenous line in the right forearm and one in the left hand. The client also has a right subclavian central venous catheter that is infusing propofol and intravenous fluids. Heart sounds are regular. The skin is pink. Capillary refill is 6 seconds. Radial pulses are equal bilaterally. Lung sounds are clear and equal bilaterally. The client has an indwelling urinary catheter in place. No urine noted. The client has no visitors at this time. The social worker is attempting to contact family members. The client opens her eyes to verbal stimuli and follows verbal commands.

heart rate 128 beats/minute, rhythm sinus tachycardia

respiratory rate 14 breaths/minute

oxygen saturation 100% on 40% fraction of inspired oxygen

temperature 96.9° F (36.1° C)

blood pressure 90/79 mm Hg

Pulse pressure calculated to be less than 40 mm Hg

The client's surgical dressing is clean and dry

Ecchymosis noted on the abdomen around the dressing

Capillary refill is 6 seconds

Radial pulses are equal bilaterally

Lung sounds are clear and equal bilaterally

No urine noted

Answer and Explanation

The Correct Answer is ["A","D","E","F","H","I","L"]

Rationale for Correct Choices:

Heart rate 128 beats/minute, sinus tachycardia: The elevated heart rate of 128 beats/minute suggests tachycardia, which could indicate hypovolemia or shock, especially given the traumatic nature of the injury. This warrants immediate attention to prevent cardiovascular compromise.
Temperature 96.9° F (36.1° C): A low temperature is concerning in trauma patients and could indicate hypothermia, which worsens in a critical setting. It should be monitored closely and actively managed, especially in the ICU setting.
Blood pressure 90/79 mm Hg, pulse pressure less than 40 mm Hg: A pulse pressure of less than 40 mm Hg can be a sign of insufficient perfusion and is concerning in trauma. The low blood pressure in combination with the narrowed pulse pressure suggests the possibility of hemorrhagic shock, which requires immediate intervention to stabilize blood volume.
Ecchymosis noted on the abdomen around the dressing: Ecchymosis around the abdominal dressing, combined with the history of trauma and CT findings of liver and spleen lacerations with peritoneal blood, strongly indicates ongoing internal bleeding.
Capillary refill is 6 seconds: Delayed capillary refill is a sign of poor peripheral perfusion, which can be indicative of hypovolemic shock or other circulatory compromise. This finding should be addressed promptly to assess circulatory status and address underlying causes.
No urine noted in the indwelling urinary catheter: The absence of urine output is a critical finding, especially in a trauma patient. It may indicate renal hypoperfusion due to low blood pressure, which can lead to acute kidney injury.

Rationale for Incorrect Choices:

Respiratory rate 14 breaths/minute: A respiratory rate of 14 breaths/minute is within the normal range for an adult. There are no signs of respiratory distress, so it does not require urgent attention at this time.
Oxygen saturation 100% on 40% fraction of inspired oxygen (FiO2): The oxygen saturation is 100%, which is within the normal range. The use of 40% FiO2 is appropriate for intubated patients, and no immediate intervention is needed for oxygenation at this time.
Surgical dressing is clean and dry: The surgical dressing being clean and dry suggests there is no active bleeding at the moment, it does not require urgent intervention unless there are signs of worsening or internal bleeding.
Lung sounds are clear and equal bilaterally: Clear lung sounds indicate that there are no immediate respiratory issues such as fluid buildup or obstruction. This is a positive finding and does not require urgent attention at this time.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

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

Explanation

A. Use standard precautions and wear a mask: Standard precautions are necessary for all patients, but wearing a mask is not specifically required for MRSA unless there is suspicion of respiratory involvement. The focus should be on contact precautions rather than masking.

B. Explain the purpose of a low bacteria diet: A low bacteria diet is not necessary for a client with MRSA unless the client is immunocompromised. The main focus should be on preventing MRSA transmission and managing the infection at the wound site.

C. Send wound drainage for culture and sensitivity: Sending the wound drainage for culture and sensitivity is essential for identifying the causative organism and determining appropriate antibiotic treatment for MRSA. This helps guide therapy and ensure proper management.

D. Institute contact precautions for staff and visitors: Contact precautions are critical for preventing spread of MRSA, especially in wound care situations. The nurse should ensure all staff and visitors follow these precautions to protect others and minimize transmission risk.

E. Monitor the client's white blood cell count: Monitoring the white blood cell count is important as it helps assess the client's immune response to infection. An elevated count may indicate the presence of infection, and close monitoring helps guide treatment decisions.

A. Maintain strict intake and output. B. Assess warmth of extremities. C. Keep head of bed raised 45 degrees. D. Monitor blood glucose level.

Correct Answer is A

Explanation

A. Maintain strict intake and output: Maintaining strict intake and output is essential in septic shock to monitor renal function and ensure adequate perfusion. Decreased urine output can indicate worsening shock or kidney failure, which requires prompt intervention.

B. Assess warmth of extremities: Early signs of septic shock often include cool or mottled extremities due to poor circulation, which should be addressed more through perfusion monitoring than by focusing solely on warmth.

C. Keep head of bed raised 45 degrees: Elevating the head of the bed may be helpful in certain situations, but it is not the most critical intervention for septic shock. The priority is to ensure proper hemodynamic monitoring, fluid resuscitation, and organ perfusion.

D. Monitor blood glucose level: While monitoring blood glucose is important in critically ill clients, it is not the immediate priority in septic shock. Sepsis often causes hyperglycemia, but managing fluid resuscitation and organ perfusion is the most urgent intervention.

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Naxlex Comprehensive Predictor Exams

A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

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

Explanation

Correct Answer is A

Explanation

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