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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","B","E"]

Explanation

Choice A rationale

Removing resuscitation equipment from the room is a standard practice before allowing family members to view the body after an unsuccessful resuscitation. This helps to create a more peaceful and less distressing environment for the family. It also respects the dignity of the deceased and allows the family to focus on their loved one, rather than the medical interventions that were attempted.

Choice B rationale

Placing a small pillow under the head is a common practice in preparing the body for viewing by the family. This helps to position the body in a natural and peaceful manner, which can be comforting for the family. It also respects the dignity of the deceased.

Choice E rationale

Gently closing the eyes is another common practice in preparing the body for viewing by the family. This helps to give the appearance of peaceful rest, which can be comforting for the family. It also respects the dignity of the deceased.

Choice C rationale

Taking out dentures and placing them in a labeled cup is not a standard practice in preparing the body for viewing by the family. Dentures, if present, are usually left in place to maintain the natural appearance of the face.

Choice D rationale

Applying a body shroud is not a common practice in preparing the body for viewing by the family. The use of a body shroud may vary based on cultural or religious preferences, but it is not a standard procedure in many healthcare settings.

A. Transfer Patient D to an isolation room 24 hours prior to surgery. B. Increase Patient A’s oxygen to 4 L/minute via nasal cannula. C. Ensure that there are two units of packed cells available for Patient B. D. Request the dietitian to include a banana in Patient C’s breakfast tray.

Correct Answer is C

Explanation

Choice A rationale

There is no indication that Patient D, who is scheduled for an appendectomy and has a white blood cell (WBC) count of 14,000 mm² (14 x 10°/L), needs to be transferred to an isolation room 24 hours prior to surgery.

Choice B rationale

Patient A, diagnosed with emphysema and has an oxygen saturation of 94% on room air, does not necessarily need an increase in oxygen. An oxygen saturation of 94% is within normal limits.

Choice C rationale

Patient B, who is postoperative with a hemoglobin level of 8.2 mg/dL (82 g/L), may require a blood transfusion. A hemoglobin level of 8.2 mg/dL is low, and having packed cells available is a prudent measure.

Choice D rationale

Patient C, newly admitted with a potassium level of 3.8 mEq/L (3.8 mmol/L), has a normal potassium level. Including a banana in the breakfast tray is not a priority.

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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

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased.The family wishes to see the body before it is taken to the funeral home.Which interventions should the nurse take to prepare the body before the family enters the room? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

Correct Answer is C

Explanation

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A patient has been admitted to the intensive care unit (ICU) with a spinal cord injury following a motor vehicle accident.Who should be contacted to manage the progression of the patient’s care?

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Exhibits For each statement, specify if the client has an understanding or no understanding of asthma triggers. Each row must have one option selected.

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.