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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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. "You should not worry about the growth tables. They are only averages for children.": Growth charts are standardized tools used to compare a child’s development with expected norms. Dismissing the concern overlooks an important clinical sign and fails to address the parent’s valid question.

B. "Haven't you been feeding according to recommended daily allowances for children?": This response places blame on the parent and does not acknowledge the child’s medical condition. It may also create unnecessary guilt rather than offering supportive education.

C. "Does your child seem mentally slower than his peers also?": Asking about developmental delay in this way is inappropriate and insensitive. It shifts the focus to cognitive ability rather than addressing the physical growth concern directly tied to the child’s condition.

D. "The smaller size is probably due to the heart disease.": Children with congenital heart defects often experience poor growth because of increased metabolic demands and reduced energy available for growth. This response gives the parent a clear, accurate explanation while validating the concern.

A. Administer intravenous antibiotic. B. Place in high Fowler's position. C. Determine last dose of analgesic. D. Prepare for emergency surgery.

Correct Answer is D

Explanation

A. Administer intravenous antibiotic: Antibiotics are often given as part of appendicitis management, but sudden pain relief may indicate appendix rupture. At this point, the priority is rapid surgical intervention, not antibiotics alone.

B. Place in high Fowler's position: Positioning may help with comfort but does not address the urgent complication of a possible perforated appendix. It is a supportive measure, not a definitive response to the change in symptoms.

C. Determine last dose of analgesic: While it is important to know when pain medication was last administered, relying on this alone could delay recognition of a surgical emergency. Sudden absence of pain in appendicitis is rarely due to analgesia but often due to perforation.

D. Prepare for emergency surgery: A sudden decrease in pain in appendicitis is concerning for rupture, as pressure is relieved when the appendix bursts. This is a life-threatening complication requiring immediate surgical evaluation and intervention.

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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 pre-school age child with a congenital heart defect is brought to the clinic by the parent because of a fever and an earache. During the assessment, the parent asks the nurse why the child is at the 5th percentile for weight and height for age. Which response is best for the nurse to provide?

Correct Answer is D

Explanation

A client admitted with a diagnosis of appendicitis calls the nurse and states, "Do you think I'll still need surgery? My pain suddenly stopped, and I feel much more comfortable now when I bend my knees." Which action should the nurse take?

Correct Answer is D

Explanation

The nurse is performing an admission assessment for a newborn who has asymmetrical buttocks. Which assessment test results should the nurse report to the healthcare provider?

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

Patient data Exhibits The nurse considers the brief interaction with the client and the triage report. Which finding(s) should the nurse investigate further? Select all that apply.

A client's respiratory assessment reveals crackles, decreased tactile fremitus, and a dull sound in left lower chest during percussion. Which condition should the nurse document in the electronic medical record?

To evaluate the effectiveness of a male client's new prescription for ezetimibe, which action should the clinic nurse implement?

The nurse applies a blood pressure cuff around a client's left thigh. To measure the client's blood pressure, where should the diaphragm of the stethoscope be placed? (Mark the location on one of the images.)

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.