Exhibits

The nurse is reviewing the client's data. Which of the following findings should the nurse report to the primary health care provider immediately? Select all that apply.

Blood pressure of 90/79 mm Hg with a pulse pressure less than 40 mm Hg

Oxygen saturation of 100% on 40% FiO₂

Heart rate of 128 beats/minute, sinus tachycardia

CT scan findings of liver and spleen lacerations with blood in the peritoneum

Temperature of 96.9°F (36.1°C)

Answer and Explanation

Correct Answer : A,C,D

Choice A rationale: Blood pressure of 90/79 mm Hg with a pulse pressure less than 40 mm Hg is concerning because it indicates hypotension and a narrowed pulse pressure, which can be signs of significant internal bleeding or shock. This requires immediate medical attention to stabilize the client's condition.

Choice B rationale: Oxygen saturation of 100% on 40% FiO₂ is not a critical finding that requires immediate reporting. The client is receiving sufficient oxygen, and the saturation level indicates adequate oxygenation.

Choice C rationale: Heart rate of 128 beats/minute, sinus tachycardia is an important finding because tachycardia can indicate a response to pain, anxiety, hypovolemia, or shock. It needs to be reported to assess and address the underlying cause.

Choice D rationale: CT scan findings of liver and spleen lacerations with blood in the peritoneum are critical because they indicate significant internal injuries and active bleeding. This requires immediate surgical intervention and close monitoring.

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Correct Answer is []

Explanation

TRALI is a life-threatening condition associated with blood transfusion. The client’s symptoms, including trauma and low hemoglobin, indicate the need for transfusion. TRALI can cause acute respiratory distress shortly after transfusion. Early intervention can improve outcomes. Recognizing the signs of TRALI is essential in such scenarios.

Rationale for actions

Administer oxygen: Oxygen supplementation can help manage hypoxemia associated with TRALI. It ensures adequate oxygenation during respiratory distress. Monitor for respiratory distress: Continuous assessment helps detect worsening symptoms. Early detection can prompt timely intervention. Rationale for parameters: Oxygen saturation: Monitoring SpO2 provides real-time information on the patient’s oxygenation status. It helps determine the effectiveness of oxygen therapy. Heart rate: Tachycardia can indicate worsening respiratory distress or hypoxemia. Monitoring heart rate is crucial for early detection of complications.

Rationale for incorrect conditions

Transfusion-associated circulatory overload (TACO): TACO involves fluid overload, leading to cardiac symptoms. However, this client’s presentation suggests acute lung injury, not fluid overload. Incorrect conditions (others): Abandonment: Not applicable as the client was brought to the hospital and received care. Physical abuse: No evidence of physical abuse in this case. Self-neglect: The client is a child, and the injury was accidental, not due to neglect. The parents brought him to the hospital promptly.

A. Severe motor dysfunction determines the extent of successful habilitation. B. Brain damage with CP is not progressive but does have a variable course. C. It is one of the most common permanent physical disabilities in children. D. Continued development of the brain lesion determines the child's outcome.

Correct Answer is B

Explanation

Choice A rationale

Severe motor dysfunction indicates the degree of impairment but does not determine the extent of successful habilitation. Habilitation depends on various factors, including individual capabilities, intervention quality, and environmental support.

Choice B rationale

Brain damage with CP is not progressive, meaning it does not worsen over time. However, the effects and manifestations can vary, leading to a range of functional outcomes. This provides a realistic and hopeful perspective for the child's future.

Choice C rationale

CP is indeed one of the most common permanent physical disabilities in children, but this statement does not directly address the mother's concern about the potential progression of impaired movements.

Choice D rationale

The continued development of the brain lesion is not a characteristic of CP. The brain damage is static, meaning it does not change, although its effects may become more apparent as the child grows and develops.

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Exhibits The nurse is reviewing the client's data. Which of the following findings should the nurse report to the primary health care provider immediately? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

Correct Answer is B

Explanation

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The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?

The nurse is preparing to administer a formula feeding by nasogastric tube (NGT) to a 2-month-old. Which intervention should the nurse implement?

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

Exhibits

The nurse is reviewing the client's data. Which of the following findings should the nurse report to the primary health care provider immediately? Select all that apply.