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Exhibits

The nurse is caring for the client.

Which of the following assessment findings should the nurse prioritize?

Heart rate 121 beats/minute

Capillary refill 2 seconds

Respirations 28 breaths/minute with shallow breathing

Radial and pedal pulses 2+

Severe abdominal pain in right lower quadrant

Feels anxious

Temperature 100.8° F (38.2° C)

Vomiting small amounts of green bile

Blood pressure 115/76 mm Hg

Answer and Explanation

Correct Answer : A,C,E,G,H

A.   Tachycardia indicates the body is responding to pain, infection, or potential sepsis. It's a critical vital sign indicating the body's stress response.
B.   Tachypnea can be a response to pain or anxiety but also indicates the need for careful monitoring of respiratory status, especially postoperatively.

C.   A capillary refill of 2 seconds is within the normal range and indicates adequate peripheral perfusion.
D.   Radial and pedal pulses 2+ are within the normal range and indicates adequate peripheral perfusion.
E.   Severe abdominal pain in the right lower quadrant is a primary symptom of appendicitis, which is confirmed by the CT scan showing a dilated appendix and fat stranding. Immediate attention is needed to address potential complications such as rupture.
F.   Feeling anxious needs to be managed to promote patient comfort. However, it doesn’t need to be managed immediately since it is not life-threatening.
G.   Fever is a sign of infection or inflammation, common in appendicitis. Monitoring and managing fever is crucial in preventing further complications.
H.   Bilious vomitus is a common finding in appendicitis and may indicate that the inflammation has progressed to a point where it is causing a blockage in the intestines. This obstruction can lead to increased pressure within the abdominal cavity and compromise blood flow, potentially resulting in a life-threatening situation.
I.   A blood pressure of 115/76 mm Hg is within normal limits and indicates stable hemodynamics at this point.

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Correct Answer is B

Explanation

A. A blood alcohol level of 0.09% indicates intoxication but is less immediately critical than lithium toxicity.
B. A serum lithium level of 1.6 mEq/L indicates lithium toxicity, which can be life- threatening and requires immediate medical intervention.
C. Significant weight loss is concerning but not as acute an issue as potential lithium toxicity.
D. Lack of sleep is serious but is a symptom that can be managed; it is not as urgent as addressing potential lithium toxicity.

A. Talk loudly into the affected ear. B. Repeat information to the client. C. Speak directly facing the client. D. Write information on a whiteboard.

Correct Answer is C

Explanation

A. Speaking loudly into the affected ear may not effectively communicate the information.
B. Repeating information is helpful but does not address the specific needs related to unilateral hearing loss.
C. Speaking directly facing the client ensures optimal communication by allowing the client to read lips and observe facial expressions.
D. Writing information on a whiteboard may be useful for some clients but does not directly address the client's hearing loss.

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Exhibits The nurse is caring for the client. Which of the following assessment findings should the nurse prioritize?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client with unilateral hearing loss is admitted for a scheduled surgery. Which technique should the nurse use to provide education about pain relief options?

Correct Answer is C

Explanation

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Exhibits

The nurse is caring for the client.

Which of the following assessment findings should the nurse prioritize?