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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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Free Nursing Study Resources

Correct Answer is ["A","D","E","H"]

Explanation

A. Apply warm blankets: Warm blankets are a safe, noninvasive method to prevent further heat loss and support gradual rewarming in a client with hypothermia. They help increase comfort and core temperature.

B. Administer an antipyretic: Antipyretics lower fever caused by infection or inflammation. This client has hypothermia, not hyperthermia, so this action would worsen the condition rather than improve it.

C. Place ice packs around the client's head: Ice packs are used for hyperthermia management, not hypothermia. Applying them would further reduce core body temperature and increase the risk of complications.

D. Check the temperature of the humidified oxygen attached to the ventilator: Ensuring the oxygen is warmed and humidified prevents further heat loss through the respiratory tract, which is critical for a hypothermic intubated client.

E. Instill warm fluids in the nasogastric tube: Warmed enteral fluids can help gently increase core body temperature when administered via an NG tube, especially in prolonged hypothermia management.

F. Microwave a pack of gauze and distribute across the body: This method is unsafe because microwaving medical supplies is not a controlled or standardized rewarming method, posing a risk of burns or uneven heating.

G. Administer intravenous fluids with a rapid infuser: A rapid infuser increases infusion speed, not temperature. If fluids are not warmed, this may worsen hypothermia.

H. Use a fluid warmer for intravenous fluids: Actively warming IV fluids before administration is a safe and effective method to prevent further heat loss and correct hypothermia in critically ill clients.

A. Irrigate conjunctiva with ophthalmic saline prior to instilling antibiotic ointment. B. Limit exposure to sunlight during the first 2 weeks when the cornea is healing. C. Avoid straining at stool, bending, or lifting heavy objects. D. Do not read without direct lighting for 6 weeks.

Correct Answer is C

Explanation

A. Irrigate conjunctiva with ophthalmic saline prior to instilling antibiotic ointment: Routine irrigation is not typically necessary unless instructed for debris removal. Over-manipulation may increase the risk of infection or injury to the healing eye.

B. Limit exposure to sunlight during the first 2 weeks when the cornea is healing: While sunglasses can protect the eyes from UV light, strict limitation of sunlight is not usually required for 2 weeks. Standard protective measures and avoiding direct glare are sufficient.

C. Avoid straining at stool, bending, or lifting heavy objects: These activities increase intraocular pressure, which can compromise the surgical site and healing process after cataract extraction. Avoiding them is critical to prevent complications such as wound dehiscence or hemorrhage.

D. Do not read without direct lighting for 6 weeks: Reading is generally safe after cataract surgery as long as the client uses appropriate lighting. There is no standard requirement to avoid reading for 6 weeks.

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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.

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits The nurse is concerned about the client's temperature. Which intervention(s) can the nurse use to address the client's temperature? Select all that apply.

Correct Answer is ["A","D","E","H"]

Explanation

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Correct Answer is C

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.