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Patient Data

Exhibits

Click to highlight the assessment findings that require immediate follow up by the nurse.

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 ["3750"]

Explanation

Convert the weight to kilograms, knowing that 1 kilogram equals 2.2 pounds. The child weighs approximately 25 kilograms (55 ÷ 2.2). Then, multiply the weight in kilograms by the prescribed amount of medication, which is 150 mg/kg/day.

So, 25 kg × 150 mg/kg/day equals 3750 mg/day.

A. Soft abdomen, absent bowel sounds, no bleeding on dressing. B. History of vomiting at home for 3 days prior to surgery. C. Peripheral pulses present with full range of motion of both legs. D. Declining to take ice chips despite reporting of dry mouth.

Correct Answer is D

Explanation

A. This information is crucial as it provides insight into the client's abdominal assessment post- laparotomy. A soft abdomen with absent bowel sounds suggests normal bowel function has not yet returned, which is common after abdominal surgery. However, this does not have immediate postoperative implications.

B. A history of vomiting prior to surgery could indicate a gastrointestinal issue that may impact the client’s recovery or increase the risk of complications such as nausea and vomiting postoperatively.However, this history may not immediately affect the current postoperative care as much as some other findings (such as changes in bowel sounds or bleeding) in the acute postoperative period.

C. This information provides reassurance regarding circulation and mobility of the lower extremities. However, it may not be as urgent to report immediately unless there were concerns during surgery or potential complications related to positioning or circulation.

D.This should be reported to ensure that the client is receiving proper hydration and that their hydration status is carefully monitored. It’s especially important to monitor for dehydration or difficulties with oral intake following surgery.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A child who weighs 55 lb receives a prescription for cefotaxime 150 mg/kg/day IV in divided doses every 6 hours. How many mg should the nurse administer each day? (Enter numerical value only.)

Correct Answer is ["3750"]

Explanation

Correct Answer is D

Explanation

A client is admitted to the mental health unit for feelings of depression secondary to a positive HIV report. To provide a safe milieu for this client, which action should the nurse take?

In caring for a client following a head injury, the nurse plans to assess for rhinorrhea so that a sample can be tested for the presence of cerebrospinal fluid (CSF). At which location should the nurse observe for this finding? (Click the chosen location. To change, click on the new location.)

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?

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

Exhibits The nurse discusses the keep to balance energy intake and output to maintain weight Click to indicate whether the following actions would be effective or ineffective for this client to achieve energy balance. Each row must have one option selected.