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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 C

Explanation

Rationale

A. This is not appropriate because a high HDL level (85 mg/dL) is beneficial and does not typically necessitate medication therapy solely for raising HDL.

B. This is reasonable to assess overall cardiovascular risk factors, including hereditary factors, which can influence the management and prevention of heart disease.

C. It reinforces the positive impact of a high HDL level on reducing cardiovascular risk and provides the client with valuable information about their health status.

D. While dietary advice is important, specifically targeting fatty foods may not be necessary if the client's HDL level is already high. General dietary recommendations for heart health are beneficial but should be tailored to individual needs.

A. Drink electrolyte fluid replacements. B. Resume normal physical activity. C. Give a dose of regular insulin as prescribed. D. Measure urine output over the next 24 hours.

Correct Answer is C

Explanation

Rationale

A. This option may seem reasonable, as dehydration and electrolyte imbalances are concerns in DKA. However, simply drinking electrolyte fluids without addressing the underlying cause of DKA (which is insulin deficiency) would not effectively manage the condition.

B. Physical activity may exacerbate DKA if insulin levels are inadequate. It is important to stabilize blood glucose levels and manage DKA before engaging in physical activity.

C. In DKA, there is an absolute or relative deficiency of insulin, leading to hyperglycemia and ketosis. Regular insulin helps to lower blood glucose levels and inhibit further breakdown of fats into ketones, thereby correcting the metabolic imbalance associated with DKA.

D. Monitoring urine output is important in assessing hydration status, but it does not address the immediate need to manage DKA. This action alone would not correct the underlying cause of increased thirst in DKA.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A older adult client tells the nurse that of having a high-density lipoprotein (HDL) level of 85 mg/dL (2.2 mmol/L). Which action should the nurse take? Reference Range: High Density Lipoproteins (HDL) [greater than 45 mg/dL (greater than 0.75 mmol/L)]

Correct Answer is C

Explanation

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?

Correct Answer is C

Explanation

An older client with osteoarthritis reports increasing pain and stiffness in the right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of the symptoms?

Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. Which action should the nurse take?

The nurse is teaching dietary modifications to a client with hypertension. Which product is the best selection to include as part of the client's lunch?

Exhibits After the nurse assesses the client, the healthcare provider writes prescriptions. The nurse reviews the prescriptions. Which 2 prescriptions should the nurse complete first?

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

A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath with activity. Which test should the nurse schedule the client for evaluation of the symptoms?

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?