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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.

Bone misalignment

Decreased range of motion

Left arm that is cool to touch

Swelling at the site of injury

Blood pressure of 136/90 mm Hg

Intense pain reported by client

Oxygen saturation 95% on room air

Answer and Explanation

Correct Answer : A,B,C,D,F

A. Bone misalignment - The nurse’s notes mention that the collarbone appears out of alignment on the left side. This could indicate a fracture or dislocation and should be investigated further.

B. Decreased range of motion - The client reports an inability to move his left arm. This could be due to the pain or a result of the injury and should be investigated further.

C. Left arm that is cool to touch - Decreased temperature in a limb can indicate poor circulation, which could be a result of the injury. This should be investigated further.

D. Swelling at the site of injury - Swelling and bruising are present on the client’s shoulder. This is a common sign of injury and should be investigated further.

E. Blood pressure of 136/90 mm Hg - While this blood pressure is not extremely high, it is on the higher end of normal. Given the client’s age and the stress of the situation, it would be worth monitoring.

F. Intense pain reported by client - The client reports a pain rating of 10 on a 0 to 10 scale in the left arm. This level of pain is concerning and should be addressed.

G. Oxygen saturation 95% on room air - While an oxygen saturation of 95% is within the normal range, given the client’s recent trauma and reported nausea, it would be prudent to monitor this closely.

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Correct Answer is A

Explanation

Choice A rationale

The right foot being cool to the touch and appearing pale and blanched is a classic sign of arterial obstruction. After a cardiac catheterization via the right femoral artery, it’s possible that a clot or other obstruction could have formed, impeding blood flow to the right foot. This would cause the foot to become cool and pale due to lack of warm, oxygenated blood.

Choice B rationale

While a moist and oozing pressure dressing at the right femoral area could indicate a problem such as bleeding from the catheter insertion site, it does not specifically indicate arterial obstruction.

Choice C rationale

A downward trend in blood pressure and a rapid, irregular pulse could indicate many different problems, including shock, heart failure, or arrhythmias. However, these symptoms are not specific to arterial obstruction.

Choice D rationale

A weaker pulse distal to the femoral artery on the left foot compared to the right foot could indicate a problem with circulation to the left foot, but it does not indicate an obstruction in the right femoral artery.

A. The patient has been vomiting at home for 3 days prior to surgery. B. The patient refuses to take ice chips despite complaining of dry mouth. C. Peripheral pulses are present with full range of motion in both legs. D. The patient’s abdomen is soft, bowel sounds are absent, and there is no bleeding on the dressing.

Correct Answer is A

Explanation

Choice A rationale

The patient vomiting at home for 3 days prior to surgery is crucial information that the PACU nurse should report. This could indicate a pre-existing condition or complication that needs to be addressed in the patient’s post-operative care plan.

Choice B rationale

While the patient refusing to take ice chips despite complaining of dry mouth is an important observation, it is not as critical as the patient’s pre-operative condition (vomiting for 3 days). The refusal of ice chips could be addressed through patient education and encouragement.

Choice C rationale

The presence of peripheral pulses and full range of motion in both legs is expected and normal in a post-operative patient, unless there were complications during surgery that could affect these observations. Therefore, this information, while important, is not as critical as the patient’s pre-operative condition.

Choice D rationale

The condition of the patient’s abdomen (soft, bowel sounds absent) and the absence of bleeding on the dressing are expected observations in a patient who has undergone an exploratory laparotomy. These observations, while important, do not provide additional critical information that the PACU nurse should report.

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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

A client is two hours postoperative from a cardiac catheterization via the right femoral artery.Which assessment finding indicates arterial obstruction?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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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.