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Exhibits

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Client is admitted to the medical floor. She has mild subcostal retractions and is sitting in an upright position. Wheezes are noted throughout the lung fields. The client is pale. She has strong peripheral pulses that are equal bilaterally. Her heart rate is 122 beats/minute, blood pressure 134/85 mm Hg, oxygen saturation 91% on room air.

mild subcostal retractions

Wheezes are noted throughout the lung fields

The client is pale

heart rate is 122 beats/minute

blood pressure 134/85 mm Hg

oxygen saturation 91% on room air

sitting in an upright position

Answer and Explanation

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

Mild subcostal retractions: Subcostal retractions indicate that the muscles between the ribs are pulling inward during breathing. This is a sign of increased work of breathing and can indicate respiratory distress.

Wheezes noted throughout the lung fields: Wheezing is a high-pitched whistling sound produced during breathing, typically due to narrowed airways. It indicates airway obstruction, common in asthma exacerbations.

Client is pale: Pallor (pale skin) can indicate reduced oxygenation or perfusion to the tissues, which can occur during respiratory distress.

Heart rate of 122 beats/minute: Tachycardia (elevated heart rate) is a compensatory mechanism in response to decreased oxygen levels or increased respiratory effort.

Oxygen saturation 91% on room air: Oxygen saturation below 94% indicates hypoxemia (low blood oxygen levels), which is a critical finding requiring prompt intervention.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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

Explanation

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.

A. Soak feet daily in hot water no longer than 10 minutes. B. Include no more than 1-2 alcoholic beverages in diet per day. C. Remember exercise will not affect blood glucose levels. D. Keep any wounds covered with an antibiotic ointment.

Correct Answer is B

Explanation

Rationale

A This statement is incorrect for diabetes management. People with diabetes should avoid soaking their feet in hot water, as it can lead to burns and skin damage, which is particularly risky due to potential nerve damage (neuropathy) and poor circulation common in diabetes.

B. This statement demonstrates good understanding. Alcohol can affect blood sugar levels and should be consumed in moderation by people with diabetes. Limiting intake to 1-2 drinks per day (following healthcare provider's advice) is generally recommended to minimize the impact on blood sugar levels and overall health.

C. Exercise is crucial for managing blood glucose levels in people with diabetes. Physical activity helps muscles use glucose for energy and can lower blood sugar levels. Understanding the importance of regular exercise is key for effective diabetes management.

D. While keeping wounds covered is generally good advice to prevent infection, using antibiotic ointment on every wound is not necessary unless specifically advised by a healthcare professional. Proper wound care, including cleaning with mild soap and water, keeping the wound clean and dry, and seeking medical attention for any signs of infection

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which response by the client indicates understanding?

Correct Answer is B

Explanation

The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection indicates to the nurse that the client understands the prescribed diet? A Baked potato with skin, raw carrots.

While preparing to administer a scheduled IV medication, the client tells the nurse that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement?

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?

The healthcare provider prescribes the antibiotic cefdinir 300 mg PO every 12 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat?

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?

The nurse is preparing for discharge a client with a history of celiac disease who now has developed multiple sclerosis. Which instruction is most important for the nurse to include in the discharge teaching plan?