Exhibits

The nurse performs an initial focused assessment of the client.

Based on the client's history and assessment data, the nurse's hypothesis is that the client's vital signs are most likely the result of disease process, medication use, or neither. Each column must have at least one, but may have more than one answer selected.

Blood pressure 130/86 mm Hg

Temperature 98.9" F (37.1° C)

Oxygen saturation 88% on room air

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"}}

Blood pressure 130/86 mm Hg
- Neither Disease Process Nor Medication: This blood pressure reading is within the normal range for an adult and does not indicate a specific disease process or medication effect.
Temperature 98.9° F (37.1° C)
- Neither Disease Process Nor Medication: This temperature is within the normal range and does not indicate a specific disease process or medication effect.
Oxygen saturation 88% on room air
- Disease Process: This low oxygen saturation level is likely due to the acute asthma attack, which is a disease process affecting the client's ability to oxygenate properly.

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Correct Answer is A

Explanation

A. The elevated heart rate and respirations suggest the client may be experiencing hypoxia, especially following a thoracotomy. Administering oxygen will help improve oxygen saturation levels and address potential respiratory distress.

B. While pain management is essential, the immediate concern is ensuring adequate oxygenation.

C. Administering IV fluids may be necessary but is secondary to ensuring the client's oxygenation.

D. Encouraging the client to splint and cough is important for preventing complications but does not address the immediate issue of vital signs indicating possible respiratory compromise.

A. Joint pain. B. Low grade fever. C. Muscle atrophy. D. Hematuria.

Correct Answer is D

Explanation

A. Joint pain is a common symptom of systemic lupus erythematosus (SLE) and, while it may indicate an exacerbation of the disease, it is not the most critical finding to report.

B. A low-grade fever can signify an infection or increased disease activity but is generally not as urgent as changes in renal function or systemic involvement.

C. Muscle atrophy is a concern over time but does not pose an immediate threat to the client’s health compared to acute changes in kidney function.

D. Hematuria is significant in SLE as it can indicate renal involvement, such as lupus nephritis, which can lead to severe complications. This finding requires prompt reporting and assessment to prevent further renal damage and manage potential complications effectively.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important to report which assessment finding to the healthcare provider?

Correct Answer is D

Explanation

The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?

The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendation should the nurse encourage the client to follow?

The nurse is caring for a client who tests positive for the sexually transmitted infection (STI) gonorrhea. The client reports having sex with someone who has many partners. Which response should the nurse provide?

A client receives a prescription for 2 liters of lactated Ringer's IV to be infused over 20 hours. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?

A client who works as a data entry clerk is concerned as to how a recent diagnosis of Raynaud's syndrome is going to affect the client's job performance. Which instruction should the nurse provide this client?

Exhibits After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.