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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 {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

Rationale:

• Instruct incentive spirometry use every hour: Indicated to promote lung expansion and prevent complications such as pneumonia or atelectasis. Even though the infection is in the leg, maintaining adequate oxygenation and pulmonary function is critical in older adults with multiple comorbidities.

• Use petroleum-based lotion on skin: Contraindicated because petroleum-based products can trap moisture and bacteria, increasing the risk of worsening cellulitis or skin breakdown. Non-occlusive, water-based moisturizers are safer for diabetic or infected skin.

• Administer antibiotics: Indicated as the client has a bacterial infection (cellulitis) with erythema, warmth, swelling, and elevated WBC count. IV cefazolin is prescribed to treat the infection promptly and prevent progression to sepsis.

• Suggest that client ambulate often: Contraindicated because the affected leg is inflamed, painful, and at risk for injury or worsening edema. Early ambulation may exacerbate discomfort and impair healing; activity should be gradual and guided by pain tolerance and clinical stability.

• Encourage consumption of protein and vitamin C: Indicated to support wound healing and immune function. Adequate protein and vitamin C intake are essential for tissue repair and recovery from infection, particularly in older adults with chronic comorbidities.

• Apply thromboembolism deterrent stockings (TED): Indicated to prevent venous thromboembolism, especially since the client has limited mobility due to pain and swelling, advanced age, and comorbid conditions like heart failure and diabetes.

A. Instruct the client to cough as the suction tip is removed. B. Apply a water soluble lubricant to the catheter. C. Instill 3 mL of 0.9% sodium chloride before suctioning. D. Wear protective goggles while performing the procedure.

Correct Answer is D

Explanation

A. Instruct the client to cough as the suction tip is removed: While encouraging coughing helps clear secretions, it is not safe to ask a client to cough before suctioning; suctioning should be done with the catheter in place to remove secretions effectively.

B. Apply a water soluble lubricant to the catheter: Lubrication is not recommended for tracheostomy suctioning because it can introduce infection or interfere with effective suctioning.

C. Instill 3 mL of 0.9% sodium chloride before suctioning: Routine saline instillation is no longer recommended as it may increase the risk of infection, hypoxia, and airway irritation without improving secretion clearance.

D. Wear protective goggles while performing the procedure: Protective eyewear is essential to prevent exposure to secretions and reduce the risk of infection or contamination during tracheostomy suctioning.

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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 For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.

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

Explanation

When performing suctioning for a client with a tracheostomy, which action should the nurse include?

Correct Answer is D

Explanation

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Patient Data Exhibits Drag from Word Choices to complete the sentence. According to the laboratory values, the client has dropdown ; related to dropdown , or dropdown.

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.