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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 C

Explanation

Choice A rationale

Keeping the head of the bed raised 45 degrees is a common practice in intensive care units to prevent aspiration pneumonia. However, in the context of septic shock, this intervention is not the highest priority.

Choice B rationale

Assessing the warmth of the extremities can provide information about peripheral perfusion. Cold extremities may indicate poor perfusion, a common symptom in septic shock. However, this is not the most critical intervention in the management of septic shock.

Choice C rationale

Maintaining strict intake and output records is crucial in the management of septic shock. Fluid balance is a key component of sepsis management. Monitoring fluid balance helps ensure that the patient is adequately hydrated, which is essential for maintaining blood pressure and organ perfusion.

Choice D rationale

Monitoring the patient’s blood glucose level is important, especially if the patient is receiving insulin or has a history of diabetes. However, in the context of septic shock, this is not the highest priority.

A. Buttered whole wheat toast and coffee. B. Granola, strawberries, and tea. C. Oatmeal, banana, and herbal tea. D. Sausage, poached eggs, and milk.

Correct Answer is C

Explanation

Choice A rationale

Buttered whole wheat toast and coffee are not the best options for a patient with diarrhea. Whole wheat toast is high in fiber, which can exacerbate diarrhea. Coffee is a diuretic and can lead to further dehydration, which is a risk with diarrhea.

Choice B rationale

Granola is high in fiber and can worsen diarrhea. Strawberries, while a good source of vitamins, are also high in fiber. Tea can be dehydrating, which is not ideal when dealing with diarrhea.

Choice C rationale

Oatmeal is a bland and easily digestible food that can help to firm up the stool. Bananas are a good source of potassium and can help replace electrolytes that may be lost through diarrhea. Herbal tea is a non-caffeinated option that can help to soothe the digestive system.

Choice D rationale

Sausage is high in fat, which can worsen diarrhea. Eggs, while a good source of protein, can be hard to digest for some people and may not be the best choice during a bout of diarrhea. Milk is a common allergen and can cause digestive issues in people who are lactose intolerant.

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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.

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Naxlex Comprehensive Predictor Exams

A patient has developed signs and symptoms of septic shock following a urinary tract infection one week ago.The healthcare provider has prescribed a sepsis protocol to be initiated.Which intervention should the nurse prioritize in the plan of care?

Correct Answer is C

Explanation

What breakfast option should a nurse suggest for a 16-year-old patient suffering from diarrhea?

Correct Answer is C

Explanation

The same 68-year-old male patient from the previous as been assessed. For each of the following findings, indicate whether they are generally associated with a rotator cuff injury or a humeral fracture.

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.

Exhibits Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

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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?

The nurse is teaching an older client about the prevention of osteoporosis.Which foods should the nurse recommend to the client to increase in the diet?

A patient with septic shock develops Disseminated Intravascular Coagulation (DIC). Which pathophysiological process should the nurse identify as the cause of the coagulation problem?

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.