Patient Data

Exhibits

Click to indicate which client goal is being met by each of the client data. Each column must have at least one response selected.

Temperature 98.1° F (36.7° C)

pH 7.40

Blood pressure 112/77 mm Hg

Capillary refill 2 seconds

Pain 0 on a scale of 0 to 10

Surgical dressing dry and intact

Answer and Explanation

The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"C"}}

• Temperature 98.1°F (36.7°C): Afebrile status indicates that the body is not mounting a febrile response to pathogens, showing infection is being prevented postoperatively.

• pH 7.40: Normal pH reflects adequate perfusion and circulation after fluid resuscitation, suggesting hypovolemia has been managed effectively.

• Blood pressure 112/77 mm Hg: Stable blood pressure within normal range after fluid bolus demonstrates restoration of circulating volume, consistent with hypovolemia management.

• Capillary refill 2 seconds: Normal refill indicates improved tissue perfusion after fluid therapy, confirming adequate correction of hypovolemia.

• Pain 0 on a scale of 0 to 10: Absence of reported pain while sedated indicates comfort and relief of anxiety, showing pain control is being achieved.

• Surgical dressing dry and intact: A clean, dry surgical site without drainage supports the goal of preventing infection after abdominal trauma surgery.

• PaCO2 42 mm Hg: PaCO 2 of 42 mm Hg is within the normal range (35−45 mm Hg) and indicates effective ventilation. This is primarily an ABC or respiratory goal, not directly related to the three listed goals.

Nursing Test Bank

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Correct Answer is A

Explanation

A. Last dose and type of rescue inhaler used by the child: Knowing the timing and type of rescue medication is critical in an acute asthma exacerbation to determine if additional doses or alternative therapies are needed immediately.

B. Frequency that the child uses a rescue inhaler during the week: While important for long-term asthma management, it is less critical during an acute, life-threatening episode where immediate intervention is required.

C. Type of allergen exposure or trigger for the current episode: Identifying triggers can help prevent future episodes but does not influence immediate treatment for the child’s current severe respiratory distress.

D. Type of inhaler the child typically uses on a regular basis: Knowing routine inhalers is relevant for chronic management but does not provide immediate guidance for emergency treatment of acute airway compromise.

A. Reduced pulse distal to injury B. Decreased range of motion C. Coolness of skin D. Pain with movement E. 1+ strength in left upper extremity

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A,B"},"E":{"answers":"A"}}

Explanation

Reduced pulse distal to injury: A humeral fracture can damage surrounding vasculature, especially the brachial artery, leading to compromised circulation. This results in weak or absent distal pulses, which requires urgent evaluation for possible neurovascular compromise.

• Decreased range of motion: Both rotator cuff injury and humeral fracture commonly cause impaired shoulder mobility. A rotator cuff tear limits abduction and overhead activities, while a fracture mechanically restricts movement due to pain, swelling, or bone displacement.

• Coolness of skin: A humeral fracture can impair blood flow by compressing or injuring vessels, producing ischemic changes such as cool skin. This finding signals inadequate perfusion, which can progress to serious complications if untreated.

• Pain with movement: Both a rotator cuff tear and humeral fracture are associated with pain on movement. In a tear, the pain stems from tendon injury and inflammation, while in a fracture, bone disruption and soft tissue trauma intensify pain when the joint is moved.

• 1+ strength in left upper extremity: Weakness in the affected arm is more typical of rotator cuff injury, as tendon disruption limits muscular function and reduces lifting ability. This differs from fracture-related pain, where strength may be preserved but restricted by pain.

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Patient Data Exhibits Click to indicate which client goal is being met by each of the client data. Each column must have at least one response selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A parent brings their child, who has a history of asthma, to the emergency department (ED). The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain?

Correct Answer is A

Explanation

Patient Data <pre> Exhibits <p>For each assessment finding, click to indicate whether the findings from the client's assessment are generally associated with rotator cuff injury and/or humeral fracture. Each column must have at least one response selected.</p>

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A,B"},"E":{"answers":"A"}}

Explanation

When preparing to administer an intravenous medication through a client's triple lumen central venous catheter, the nurse observes that there are no continuous intravenous fluids infusing. Which action should the nurse take?

Which laboratory values are critical for the nurse to monitor for a client who is experiencing a thyrotoxic crisis?

The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?

The nurse is planning care for a child who is suffering from persistent itching due to scabies. Which measure should the nurse implement to minimize this child's risk for complications?

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

The nurse is caring for a client with chronic kidney disease (CKD). Which meal selection should the nurse recommend to the client?

Which finding should the nurse recognize as a potential complication in a client with hypertension?

The nurse is performing a musculoskeletal assessment with a client. Which action(s) should the nurse implement when performing passive range of motion (PROM) exercises with a client? Select all that apply.

Patient Data

Exhibits

Click to indicate which client goal is being met by each of the client data. Each column must have at least one response selected.