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Patient Data

Exhibits

The nurse places the client on a cardiorespiratory monitor and places the nasal cannula on the client. The nurse then completes an assessment and documents it in the chart.

For each body system, click to specify the assessment findings that indicates hypoxia. At least one finding could be indicated for each system.

Body System

Assessment Finding

Neurological

Restless

Awake and alert

Anxious

Respiratory

Respiratory rate 28 breaths/minute

Oxygen Saturation 90% on room air Productive cough

Cardiovascular

Heart rate 101 beats/minute Capillary refill 4 seconds

Blood pressure 145/89 mm Hg

Restless

Awake and alert

Anxious

Respiratory rate 28 breaths/minute

Oxygen Saturation 90% on room air

Productive cough

Heart rate 101 beats/minute

Capillary refill 4 seconds

Blood pressure 145/89 mm Hg

Answer and Explanation

The Correct Answer is ["A","C","D","E","G"]

Neurological: Restlessness and anxiety can both be symptoms of hypoxia due to the brain's sensitivity to changes in oxygen levels.

Respiratory: Low oxygen saturation directly indicates hypoxia, and an increased respiratory rate can be a compensatory response to low oxygen levels.

Cardiovascular: Elevated heart rate can be a compensatory mechanism for hypoxia, and delayed capillary refill may indicate poor perfusion related to low oxygen levels.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. An OGTT is not directly related to the symptoms of hypoglycemia experienced in the early morning.

B. An insulin pump is a possible treatment but is not the immediate change needed for managing hypoglycemia.

C. Diaphoresis and shakiness in the morning suggest possible nocturnal hypoglycemia, which may require a decrease in the evening dose of NPH insulin to prevent such episodes.

D. Testing glucose levels at multiple times can be part of managing diabetes but does not address the immediate need for adjustment in insulin dosing.

A. The left radial pulse is 2+ bounding. B. Distended, tortuous veins in the left hand. C. Auscultation of a thrill on the left forearm. D. Assessment of a bruit on the left forearm.

Correct Answer is ["C","D"]

Explanation

A. A bounding radial pulse does not specifically indicate the patency of an AV fistula; it is a general assessment of peripheral pulse quality.

B. Distended veins in the hand may indicate venous congestion but are not a reliable indicator of fistula patency.

C. The presence of a thrill (a palpable vibration) over the AV fistula indicates proper blood flow through the fistula.

D. The presence of a bruit (a whooshing sound) over the AV fistula indicates the flow of blood through the fistula, confirming patency.

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Body System	Assessment Finding
Neurological	Restless Awake and alert Anxious
Respiratory	Respiratory rate 28 breaths/minute Oxygen Saturation 90% on room air Productive cough
Cardiovascular	Heart rate 101 beats/minute Capillary refill 4 seconds Blood pressure 145/89 mm Hg

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with type 1 diabetes mellitus who reports experiencing diaphoresis and shakiness in the early morning hours. The nurse should expect which change in the client's treatment plan?

Correct Answer is C

Explanation

A client with chronic kidney disease (CKD) has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent? Select all that apply.

Correct Answer is ["C","D"]

Explanation

While the nurse is admitting a client with partial thickness burns to the upper extremities, chest, and abdomen, the client experiences difficulty swallowing. The client is drooling and anxious. Which intervention should the nurse implement first?

An older adult client is brought to the clinic for Increased confusion over the past three days and presents with a draining wound on the right leg. Which assessment is most important for the nurse to obtain?

A male infant with a 2-day history of fever and diarrhea is brought to the clinic by his mother who tells the nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no tears. Which prescription is most important for the nurse to implement?

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID 19. Which action is most important for the nurse to take?

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?