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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.

Left arm that is cool to touch

Decreased range of motion

Swelling at the site of injury

Intense pain reported by client

Oxygen saturation 95% on room air

Blood pressure of 136/90 mm Hg

Nausea and fatigue reported by client

Bone misalignment

Answer and Explanation

Correct Answer : A,B,D,G,H

A. Left arm that is cool to touch: A cool extremity can indicate impaired circulation, which is a priority concern after trauma. It may suggest compromised perfusion or neurovascular compromise, requiring immediate further investigation.

B. Decreased range of motion: The inability to move the left arm signals possible fracture, dislocation, or neurovascular impairment. Limited mobility after trauma should always be investigated to determine the extent of musculoskeletal injury.

C. Swelling at the site of injury: Swelling is expected following trauma and does not necessarily indicate a complication. While it should be monitored, it is not as urgent to investigate further compared with circulation or alignment changes.

D. Intense pain reported by client: Severe, constant pain out of proportion to the injury raises concern for complications such as compartment syndrome, fracture, or vascular compromise. This finding requires prompt further assessment and intervention.

E. Oxygen saturation 95% on room air: Although slightly lower than ideal, this level is still acceptable in an older adult and not immediately alarming. It does not require urgent further investigation compared to other more critical findings.

F. Blood pressure of 136/90 mm Hg: This blood pressure indicates mild hypertension but is not an acute concern in the setting of trauma. It does not require urgent investigation at this point.

G. Nausea and fatigue reported by client: These symptoms may suggest a head injury, concussion, or internal response to trauma. Given the reported head impact, these findings warrant further neurological evaluation.

H. Bone misalignment: Visible misalignment strongly suggests fracture or dislocation. This finding must be investigated further to confirm the diagnosis and prevent neurovascular complications.

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Correct Answer is D

Explanation

A. Assess the abdomen for bowel sounds: Monitoring bowel sounds is important during opioid therapy because morphine can cause constipation. However, this assessment does not take priority when initiating PCA therapy, as it does not immediately affect safe administration or pain control.

B. Initiate the dosage lockout mechanism on the PCA pump: While critical for safety, it is part of pump setup and not the first priority; assessing the client’s understanding of pain reporting comes first to ensure safe and effective use.

C. Instruct the client to use the medication before the pain becomes severe: Teaching about preemptive use improves pain control and prevents breakthrough pain, but this instruction is most effective after determining that the client can understand and use the PCA system appropriately.

D. Assess the client's ability to use a numeric pain scale: Evaluating the client’s understanding of a pain scale ensures they can accurately report pain levels and self-administer the correct dose using the PCA. This assessment is the priority because safe and effective pain management depends on the client’s ability to communicate pain accurately.

A. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds. B. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity. C. The client with an obstruction of the large intestine who is experiencing abdominal distention. D. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid.

Correct Answer is B

Explanation

A. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds: Paralytic ileus is common postoperatively and, while concerning, is usually not immediately life-threatening.

B. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity: Abdominal rigidity suggests possible bowel ischemia or perforation, which are surgical emergencies. This client is at highest risk for rapid deterioration and requires immediate assessment and intervention.

C. The client with an obstruction of the large intestine who is experiencing abdominal distention: While abdominal distention indicates obstruction, it is not immediately life-threatening unless accompanied by signs of ischemia or perforation.

D. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid: NG drainage is expected with small bowel obstruction and indicates decompression is occurring. This is less urgent than a client showing signs of peritonitis.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PСА) pump?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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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.