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Exhibits

The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.

Blood pressure of 136/90 mm Hg

Oxygen saturation 95% on room air

Bone misalignment

Left arm that is cool to touch

Swelling at the site of injury

Nausea and fatigue reported by client

Intense pain reported by client

Decreased range of motion

Answer and Explanation

Correct Answer : C,D,E,F,G

A. Blood pressure of 136/90 mm Hg while slightly elevated, is not unusual for someone in pain or distress and does not require immediate investigation.

B. Oxygen saturation 95% on room air is within the acceptable range for an adult and does not indicate immediate respiratory compromise.

C. The misalignment of the collarbone indicates a possible fracture or dislocation, which requires further assessment and imaging to confirm the extent of the injury.

D. A cool left arm could indicate compromised blood flow, possibly due to vascular injury from the trauma. This requires immediate investigation to prevent complications such as ischemia.

E. Swelling is a sign of trauma, which may indicate soft tissue damage, fractures, or inflammation. The nurse should monitor for further signs of internal bleeding or worsening injury.

F. Nausea and fatigue reported by client could suggest underlying issues such as a head injury, shock, or a systemic response to the trauma. Further evaluation is required to rule out serious complications like a concussion or other medical conditions.

G. Severe pain is a critical finding that needs prompt management. Pain assessment will guide the appropriate interventions, such as pain relief and further diagnostics to identify underlying causes.

H. While decreased range of motion is important, it is expected due to the trauma and pain from the fall. It will likely be addressed after the immediate concerns of injury and vascular status are managed.

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Correct Answer is C

Explanation

A. While safe sex practices significantly reduce the risk of STIs, they do not eliminate it entirely; thus, this statement is misleading.

B. Not all STIs are transmitted solely through sexual intercourse (e.g., some can be transmitted through non-sexual contact), making this statement too broad.

C. Explaining that reinfections occur from sexual contact with untreated partners is accurate and emphasizes the importance of treatment for both the infected person and their partners.

D. While some contraceptives may provide a barrier to STIs, not all methods are effective against infections, so this statement requires clarification.

A. 200 mL blood loss B. Fundus massaged until firm and at umbilicus. C. Blood pressure of 110/80 mm Hg, heart rate of 66 beats/min, oxygen saturation at 98% on room air D. Total blood loss of 800 mL E. Fundus remains firm with slight lochia noted on pad F. Straight catheter produced 500 mL clear yellow urine G. Multiple large clots were expelled

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"B"}}

Explanation

200 mL blood loss: Indicates ongoing bleeding, putting the client at risk for hypovolemia.

Fundus massaged until firm and at umbilicus: This indicates improved uterine tone, reducing the risk of postpartum hemorrhage.

Blood pressure of 110/80 mm Hg, heart rate of 66 beats/min, oxygen saturation at 98% on room air: Stable vital signs suggest improvement in the client’s condition.

Total blood loss of 800 mL: A total blood loss of this amount is concerning, indicating a risk for hypovolemia.

Fundus remains firm with slight lochia noted on pad: A firm fundus indicates that uterine involution is occurring properly, which is a positive sign.

Straight catheter produced 500 mL clear yellow urine: Adequate urine output indicates good kidney perfusion and hydration status.

Multiple large clots were expelled: The presence of large clots is concerning and indicates the possibility of further bleeding, putting the client at risk for hypovolemia.

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Exhibits The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having unprotected sex. Which response should the nurse provide?

Correct Answer is C

Explanation

Exhibits The nurse is reviewing the client's chart. For each finding, click to indicate whether findings suggest that the client's condition has improved or put the client at risk for hypovolemia. Each column must have at least one selection.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"B"}}

Explanation

A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? Select all that apply.

A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair. Which intervention is most important for the nurse to include in the plan of care?

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

Exhibits The nurse starts the albuterol nebulizer as prescribed. Which should the nurse assess after the albuterol nebulizer treatment is complete? Select all that apply.

The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?

An older client with osteoarthritis reports increasing pain and stiffness in the right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of the symptoms?

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

Exhibits

The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.