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 A

Explanation

Choice A rationale

Donning appropriate personal protective equipment (PPE), including an N95 respirator mask, face shield, gown, gloves, and shoe coverings, is crucial to protect the nurse from potential exposure to the virus during close contact with a symptomatic client.

Choice B rationale

Teaching the client to wear a mask, hand wash, and maintain social distance is essential for preventing virus spread but is secondary to protecting the healthcare provider while collecting a test sample from a symptomatic client.

Choice C rationale

Informing the client to notify others about potential exposure is an important step in contact tracing, but it does not directly protect the nurse during the specimen collection procedure.

Choice D rationale

Notifying the charge nurse about the client's need for assignment to a COVID-19 designated area is important for appropriate care and isolation but does not directly address immediate protection for the nurse during the testing procedure.

Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"C"}

Explanation

Rationale for correct answer:

Pain relief: The purpose of epidural anesthesia is to provide pain relief during labor. Since the nurse’s notes state that the client is comfortable and reports adequate pain relief, it demonstrates that the epidural anesthesia is effective.
Fetal heart rate: Monitoring fetal heart rate is crucial to ensure the well-being of the baby during labor. The nurse’s notes state that the fetal heart rate is within normal limits, indicating that the epidural anesthesia has not adversely affected the baby and is working effectively.

Rationale for incorrect answers:

Good urine output: While good urine output is important, it is not a direct indicator of the effectiveness of epidural anesthesia. It does not provide information about pain relief or fetal well-being.
Vital signs: Vital signs are important to monitor but do not specifically indicate the effectiveness of epidural anesthesia in terms of pain relief and fetal well-being.
Progression of labor: The progression of labor is influenced by various factors, not just the effectiveness of epidural anesthesia. It is not a direct measure of the epidural’s effectiveness.
Labor augmentation: Labor augmentation refers to interventions to stimulate labor. It is not related to the effectiveness of epidural anesthesia.

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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

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?

Correct Answer is A

Explanation

A nurse is caring for a 26-year-old gravida 2 para 1 client in the labor and delivery unit. Exhibits Drag from the Word Choices to complete the sentence. The client demonstrates effective epidural anesthesia by:dropdown and dropdown

Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"C"}

Explanation

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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.