Exhibits

The nurse reviews the prescriptions and plans initial steps for caring for the client. Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

Palpate and compare radial pulses.

Administer ondansetron 4 mg IV.

Perform range of motion.

Check capillary refill on bilateral upper extremities.

Inspect the bandage for drainage.

Provide morphine 2 mg IV push (IVP).

Answer and Explanation

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

Rationale:

Palpate and compare radial pulses: It is important to check radial pulses to assess circulation to the injured limb. Decreased pulse strength, especially in the left arm, could indicate vascular injury, which requires immediate attention.
Administer ondansetron 4 mg IV: The client is feeling nauseated and worries about vomiting, likely due to postoperative effects, pain medication, or anesthesia. Ondansetron is an antiemetic, which is appropriate to administer to manage nausea and prevent vomiting.
Check capillary refill on bilateral upper extremities: Checking capillary refill is essential to assess perfusion to both arms. The client’s left arm is experiencing coolness, and diminished pulses were noted earlier, so this is necessary to monitor blood flow and prevent complications like compartment syndrome.
Inspect the bandage for drainage: After surgery, it is important to inspect the surgical site for any drainage, bleeding, or signs of infection. This helps ensure that there are no complications or issues with wound healing.

Perform range of motion: Performing range of motion exercises is contraindicated immediately after trauma, especially with a fracture or suspected injury to the shoulder. The shoulder should be immobilized to prevent further damage and to facilitate proper healing. Early movement may worsen the injury or cause additional pain.
Provide morphine 2 mg IV push (IVP): While he had a nerve block, its effectiveness will wane, and he will likely experience significant pain from the fracture and surgical manipulation. Administering prescribed analgesia like morphine is a priority for pain management.

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Correct Answer is A

Explanation

A. Maintain strict intake and output: Maintaining strict intake and output is essential in septic shock to monitor renal function and ensure adequate perfusion. Decreased urine output can indicate worsening shock or kidney failure, which requires prompt intervention.

B. Assess warmth of extremities: Early signs of septic shock often include cool or mottled extremities due to poor circulation, which should be addressed more through perfusion monitoring than by focusing solely on warmth.

C. Keep head of bed raised 45 degrees: Elevating the head of the bed may be helpful in certain situations, but it is not the most critical intervention for septic shock. The priority is to ensure proper hemodynamic monitoring, fluid resuscitation, and organ perfusion.

D. Monitor blood glucose level: While monitoring blood glucose is important in critically ill clients, it is not the immediate priority in septic shock. Sepsis often causes hyperglycemia, but managing fluid resuscitation and organ perfusion is the most urgent intervention.

A. Electrolytes B. Coagulation studies C. Blood culture D. Lipid panel E. Complete blood count F. Urine osmolality G. Arterial blood gas H. Type and screen

Correct Answer is ["A","B","E","G","H"]

Explanation

A. Electrolytes: Electrolytes are important to monitor in this client due to potential blood loss and altered kidney function. Electrolyte imbalances (especially sodium and potassium) can affect heart function, muscle strength, and overall fluid balance, which is crucial after trauma and surgery.

B. Coagulation studies: Given the trauma (liver and spleen lacerations), the client is at risk for bleeding. Coagulation studies (including PT, INR, and aPTT) are necessary to assess the clotting ability and manage bleeding risk, particularly before surgery or when planning for interventions.

C. Blood culture: While blood cultures are important for identifying infections, there is no immediate indication of infection in this patient at this point in time. The priority is stabilizing the patient and managing trauma and bleeding.

D. Lipid panel: A lipid panel is not a priority at this moment. It is generally used to assess cardiovascular risk and would not provide immediate information relevant to managing acute trauma and bleeding.

E. Complete blood count (CBC): A CBC is essential to assess for anemia, infection, or other hematologic abnormalities, especially in trauma patients with possible internal bleeding. Hemoglobin and hematocrit levels provide information about blood loss and oxygen-carrying capacity.

F. Urine osmolality: Urine osmolality is useful for assessing kidney function and hydration but is not immediately necessary in this trauma case. The priority is stabilizing the patient's circulatory and respiratory status, with more focus on urine output and renal function.

G. Arterial blood gas (ABG): An ABG is crucial to assess the client’s oxygenation, ventilation, and acid-base status, especially since the client is intubated and on a ventilator. This will help in monitoring respiratory function and ensuring proper oxygen delivery.

H. Type and screen: The client has a history of trauma and potential internal bleeding. It is essential to know her blood type and ensure compatibility for any potential blood transfusions, particularly before the exploratory laparotomy and any possible further blood loss.

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Exhibits The nurse reviews the prescriptions and plans initial steps for caring for the client. Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Exhibits Which laboratory tests would be helpful in determining the plan of care for this client? Select all that apply.

Correct Answer is ["A","B","E","G","H"]

Explanation

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Exhibits Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. Based on the client's condition, the priority need will be to addressdropdown. In addition, he will need interventions to preventdropdown.

Exhibits

The nurse reviews the prescriptions and plans initial steps for caring for the client. Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.