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 B

Explanation

A. Bronze pigmentation is often associated with venous insufficiency rather than arterial compromise.

B. Compromised peripheral arterial circulation can lead to decreased blood flow, resulting in uneven or diminished hair distribution on the lower extremities due to lack of nourishment to hair follicles.

C. Lower leg edema is more commonly associated with venous insufficiency rather than arterial insufficiency.

D. A bounding peripheral pulse indicates increased arterial pressure or volume, which is not consistent with compromised arterial circulation, where pulses are typically weak or absent.

A. Provide frequent mouth care. B. Maintain the client in a semi-Fowler's position. C. Ensure oral suction is available. D. Keep the room at a comfortable temperature.

Correct Answer is C

Explanation

A. While frequent mouth care is important, it is not the most immediate concern during an active seizure. The priority is to maintain airway patency and prevent aspiration.

B. Maintaining a semi-Fowler's position may be beneficial, but the client’s level of consciousness and the presence of seizures require more immediate interventions focused on airway management.

C. Ensuring oral suction is available is essential for the client who is unconscious and experiencing seizures, as it allows for rapid intervention to clear secretions and prevent aspiration, which is critical for airway protection.

D. Keeping the room at a comfortable temperature is important for the overall comfort of the client, but it does not directly address the acute management of seizures and airway concerns.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of compromised peripheral arterial circulation of the lower extremity?

Correct Answer is B

Explanation

The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is most essential in this client's plan of care (POC)?

Correct Answer is C

Explanation

While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?

Exhibits The nurse has implemented additional needed actions. Click the assessment data which indicates the interventions were successful and which assessment data provides no indication that the interventions were successful. Each column must have at least one answer selected.

The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

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?

The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?

A client presents to the emergency department reporting chest pain that is radiating to the left arm, shortness of breath, and diaphoresis. Which medication should the nurse anticipate being prescribed by the healthcare provider?