Patient Data
Click to highlight the findings that would indicate the client is progressing as expected.
The nurse assesses the client. The client reports he was able to sleep through the night. The client notes continued numbness in his left arm, along with a tingling sensation, and is not able to move his fingers. The client reports mild nausea and has no desire to eat breakfast. There is a 1.18 in (3 cm) by 1.97 in (5 cm) area of blood noted on the bandage. The left arm is warm to touch. The client's left shoulder and collarbone are symmetric.
The client reports he was able to sleep through the night
continued numbness in his left arm, along with a tingling sensation, and is not able to move his fingers
The client reports mild nausea and has no desire to eat breakfast
There is a 1.18 in (3 cm) by 1.97 in (5 cm) area of blood noted on the bandage
The left arm is warm to touch
The client's left shoulder and collarbone are symmetric.
The Correct Answer is ["A","E","F"]
Rationale for Correct Choices:
- The client reports he was able to sleep through the night: Adequate rest indicates improved comfort and effective pain management postoperatively.
- The left arm is warm to touch: Warmth confirms adequate circulation and tissue perfusion following surgery.
- The client's left shoulder and collarbone are symmetric: Symmetry suggests proper surgical alignment and absence of acute displacement or swelling.
Rationale for Incorrect Choices:
- Continued numbness in the left arm, tingling, and inability to move fingers: These findings raise concern for possible neurovascular compromise or prolonged effects of the nerve block.
- Mild nausea and lack of desire to eat breakfast: This can be a transient side effect of anesthesia or analgesics but requires monitoring for persistence.
- A 3 cm × 5 cm area of blood noted on the bandage: Postoperative dressings should have minimal drainage, so this amount of blood warrants assessment for active bleeding or hematoma formation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
A. Instruct to give additional dose if the baby vomits after administration: Giving an extra dose after vomiting can result in digoxin toxicity because the exact amount absorbed is uncertain. Parents should never repeat a dose without consulting the healthcare provider.
B. Demonstrate how to measure the correct amount of the oral solution: Accurate measurement is critical for safe digoxin administration, as small errors can lead to underdosing or toxicity. Using an appropriate oral syringe or dropper ensures the correct dose.
C. Notify the healthcare provider before giving digoxin if your baby is ill: Illness can affect heart rate, hydration, and electrolyte balance, which increases the risk of digoxin toxicity. Parents should contact the provider to determine whether to hold or adjust the dose.
D. Show the correct technique to obtain an apical pulse: Digoxin can slow the heart rate. Parents should learn to assess the apical pulse for a full minute and understand the parameters for withholding medication based on heart rate guidelines.
E. Administer digoxin on a strict every 12-hour schedule: Maintaining consistent timing ensures stable blood levels, improving efficacy and reducing the risk of toxicity. A strict schedule is essential for therapeutic effectiveness.
Correct Answer is D
Explanation
A. Place the client in the Trendelenburg position: While this position may increase venous return, it does not address the underlying cause in a pregnant client, which is usually aortocaval compression by the uterus. Simply tilting the table may be less effective than proper lateral displacement.
B. Remove the client's legs from the stirrups: Removing the legs may relieve some discomfort but does not correct the maternal hypotension caused by pressure on the inferior vena cava. Additional interventions are needed to improve circulation.
C. Instruct the client to take deep breaths: Deep breathing may help with anxiety or mild shortness of breath but does not resolve the hemodynamic compromise caused by supine hypotensive syndrome.
D. Place a wedge under the client's hip: Placing a wedge under the right or left hip tilts the uterus off the inferior vena cava, improving venous return, cardiac output, and blood pressure. This is the priority action to relieve dizziness, pallor, and diaphoresis in a pregnant client at 26 weeks’ gestation.
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