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Patient Data

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.

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Correct Answer is A

Explanation

Rationale

A. Monitoring intake and output closely is essential to assess fluid balance and ensure adequate hydration. Replacing fluids intravenously based on this assessment helps maintain hemodynamic stability and prevent dehydration, electrolyte imbalances, and hypovolemia.

B. After surgery for fistula repair, it is important to monitor wound drainage to assess for complications such as infection or delayed healing. Excessive drainage may indicate issues with wound healing or ongoing inflammation, requiring timely intervention.

C. Turning the client every 2 hours helps prevent complications such as pressure ulcers and respiratory complications. It promotes circulation, prevents skin breakdown, and aids in lung expansion. However, while important, this intervention is more focused on preventing physical complications rather than directly addressing the client's immediate medical needs post-surgery.

D. Clients with inflammatory bowel disease, especially those undergoing surgery and critically ill, are at increased risk for skin breakdown due to factors such as decreased mobility, medication effects, and overall health status. Regular skin assessments help detect early signs of breakdown and allow for prompt intervention to prevent pressure ulcers or skin complications.

A. Keep the nails trimmed short. B. Bathe the child daily with bath oil. C. Apply baby lotion to the skin twice daily. D. Allow the child to wear only 100% cotton clothing.

Correct Answer is A

Explanation

Rationale

A. Children with eczema often scratch their itchy skin, which can lead to skin breakdown, bleeding, and secondary infections. Short nails minimize the trauma inflicted on the skin during scratching and help prevent complications.

B. Bathing helps to hydrate the skin and remove allergens, bacteria, and other irritants that can exacerbate eczema. Bathing daily with bath oil helps to moisturize the skin and prevent dryness. Bath oils or emollients should be used instead of harsh soaps, which can strip the skin of natural oils and worsen dryness. However, it's essential to ensure the water is not too hot and to limit bath time to avoid drying out the skin.

C. Moisturizing the skin is a cornerstone of eczema management. Applying a moisturizer, such as baby lotion or emollient cream, helps to hydrate the skin, reduce dryness, and protect the skin barrier. Moisturizers should ideally be applied at least twice daily, especially after bathing or showering when the skin is damp to lock in moisture. Choosing a moisturizer that is fragrance-free and hypoallergenic is beneficial to avoid further irritation.

D. Cotton clothing is recommended for children with eczema because it is breathable and less likely to irritate sensitive skin compared to synthetic fabrics. Cotton allows better air circulation around the skin, which can help prevent overheating and sweating, both of which can exacerbate eczema symptoms. Avoiding wool and synthetic fabrics that can cause friction and irritation is important.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

The nurse is assessing a 4-year-old client with eczema. The child's skin is dry and scaly, and the parent reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child?

Correct Answer is A

Explanation

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

A client is admitted to the intensive care until (ICU) with a spinal cord injury following a motor vehicle collision. Which nurse should be contacted to coordinate the progression of the client's care?

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)]

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

An older adult client with dementia who is refusing to allow an unlicensed assistive personnel (UAP) to assist in bathing, is becoming increasingly agitated and stating the UAP "wants to hurt me and tie me up." Which approach should the nurse use with the client?