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Exhibits

The nurse reviews the nurse's notes and flow chart to identify trends.

Click to specify the notations that require immediate follow up (more than one notation may be correct.)

Body System

Circulatory

Heart rate 96 beats/minute

Blood pressure 90/62 mm Hg

IV infusing at 125 ml/hr

Respirations 16 breaths/minute

Respiratory

Oxygen saturation of 89%

Several deep breaths

Integumentary

Episiotomy intact with no redness

Pad is saturated with blood

18 gauge IV to left forearm

Genital/Urinary

Boggy fundus 1 cm above umbilicus

Fundus rotated to the right

Voided 200 mL of clear yellow urine

Blood pressure 90/62 mm Hg

Oxygen saturation of 89%

Fundus rotated to the right

Voided 200 mL of clear yellow urine

Oxygen saturation of 89%

IV infusing at 125 ml/hr

Answer and Explanation

The Correct Answer is ["A","B","C"]

Blood pressure 90/62 mm Hg

A blood pressure of 90/62 mm Hg indicates hypotension, which could be indicative of hypovolemia (low blood volume) due to postpartum hemorrhage. Hypotension needs immediate evaluation and intervention to prevent further complications.

Oxygen saturation of 89%

An oxygen saturation of 89% on room air is below the normal range (typically 95-100%). This suggests the client is not adequately oxygenating, which could be due to various reasons such as respiratory compromise or inadequate ventilation. Immediate follow-up is necessary to determine the cause and initiate appropriate interventions.

Fundus rotated to the right

The displacement of the fundus could be due to the presence of a distended bladder pushing the uterus to one side which may increase uterine atony.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Rationale

A. While support groups are important for individuals dealing with chronic illnesses or specific health issues, they are not directly related to primary disease prevention. Support groups focus more on coping, emotional support, and managing existing conditions rather than preventing diseases.

B. Domestic violence assistance is crucial for community health and safety, but it is not typically categorized under primary disease prevention. Domestic violence is a social issue that requires interventions aimed at prevention and support for victims, rather than preventing diseases through health promotion and education.

C. Blood pressure screening is an example of a primary disease prevention activity. High blood pressure (hypertension) is a significant risk factor for cardiovascular diseases such as heart attack and stroke. By screening individuals for hypertension, nurses can identify those at risk early and provide education on lifestyle modifications or medical interventions to prevent cardiovascular disease.

D. Immunizations are a cornerstone of primary disease prevention. Vaccines prevent infectious diseases by stimulating the immune system to produce immunity against specific pathogens. Community outreach programs that educate the public about immunizations help increase vaccination rates, thereby reducing the incidence of vaccine-preventable diseases in the population.

A. The pressure dressing at right femoral area is moist and oozing blood. B. Pulse distal to the femoral artery is weaker on left foot than right foot. C. Right foot is cool to the touch and appears pale and blanched. D. Blood pressure trend is downward and pulse is rapid and irregular.

Correct Answer is C

Explanation

A. While bleeding can occur postoperatively from the catheter insertion site, it is more indicative of venous or capillary bleeding rather than arterial obstruction. Arterial obstruction typically presents with signs related to decreased arterial blood flow rather than external bleeding.

B. This finding suggests a difference in peripheral pulses between the two lower extremities. While it could indicate arterial compromise, the question specifically asks about arterial obstruction at the site of the catheterization (right femoral artery).

C. This finding is concerning for arterial obstruction. Coolness, pallor, and blanching of the right foot indicate decreased arterial blood flow to the extremity. Arterial obstruction can lead to reduced perfusion distal to the occlusion site, resulting in these clinical signs.

D. These vital sign changes could indicate systemic complications, such as shock, rather than isolated arterial obstruction at the femoral artery site. While systemic changes can occur secondary to arterial obstruction, they are not specific indicators of obstruction at the femoral artery.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event?

Correct Answer is D

Explanation

The nurse is caring for a 3-year-old client who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?

Correct Answer is C

Explanation

An unresponsive victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save the client's life. The client is accompanied by a close friend, but no family members are available. Which action should the nurse take first?

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having unprotected sex. Which response should the nurse provide?

The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

Exhibits Which client statement(s) require(s) follow up teaching by the nurse? Select all that apply.

When developing a teaching plan for a client with newly diagnosed type 1 diabetes mellitus, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?

Exhibits The nurse is reviewing the client's chart. For each finding, click to indicate whether findings suggest that the client's condition has improved or put the client at risk for hypovolemia. Each column must have at least one selection.

A client arrives to the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?

A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair. Which intervention is most important for the nurse to include in the plan of care?