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Patient Data

Exhibits

Review H and P and nurse's notes.

Click to highlight which assessment finding(s) should the nurse attend to right away?

Admitted client.

Vital signs

Temperature: 96.9° F (36.1° C) internal probe via urinary catheter

Heart rate: 128 beats/minute, sinus tachycardia (ST)

Respirations: 14 breaths/minute

Patient Data

Blood pressure: 90/79 mm Hg, pulse pressure less than 40 mm Hg

Oxygen saturation: 100% on 40% fraction of inspired oxygen (FiO2)

The client's surgical dressing is clean and dry. Ecchymosis noted on the abdomen around the dressing. The client has a PIV line in the right forearm and one in the left hand. The client also has a right subclavian central venous catheter that is infusing propofol and intravenous fluids. Heart sounds are regular. The skin is pink. Capillary refill is 6 seconds. Radial pulses are equal bilaterally. Lung sounds are clear and equal bilaterally. The client has an indwelling urinary catheter in place. No urine noted. The client has no visitors at this time. The social worker is attempting to contact family members. The client opens her eyes to verbal stimuli and follows verbal commands.

Heart rate: 128 beats/minute, sinus tachycardia (ST)

Blood pressure: 90/79 mm Hg, pulse pressure less than 40 mm Hg

The client's surgical dressing is clean and dry

Ecchymosis noted on the abdomen around the dressing.

Heart sounds are regular.

Capillary refill is 6 seconds.

The client has an indwelling urinary catheter in place. No urine noted.

Answer and Explanation

The Correct Answer is ["A","B","F","G"]

Rationale for correct choices

• Heart rate 128 beats/minute, sinus tachycardia: Tachycardia signals early compensatory response to hypovolemia or hemorrhagic shock, common with abdominal trauma. Immediate attention is needed to prevent cardiovascular collapse.
• Blood pressure 90/79 mm Hg, pulse pressure less than 40 mm Hg: A narrow pulse pressure with low systolic BP suggests inadequate stroke volume and poor perfusion, consistent with ongoing internal bleeding.
• Capillary refill 6 seconds: Prolonged refill indicates impaired peripheral perfusion and circulatory compromise, reinforcing concerns of shock.
• No urine output: Absence of urine is a critical marker of inadequate renal perfusion and systemic hypoperfusion, reflecting worsening shock status.

Rationale for incorrect choices

• Temperature 96.9° F (36.1° C): Slightly low but not critical; mild hypothermia is common post-trauma and can be managed after stabilizing perfusion.
• Surgical dressing clean/dry with ecchymosis: Ecchymosis is expected after trauma and surgery, requiring monitoring but not immediate intervention.
• Heart sounds regular, lung sounds clear: No acute cardiopulmonary decompensation detected.

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Free Nursing Study Resources

Correct Answer is ["0.6"]

Explanation

Calculation:

Convert the client's weight from pounds (lb) to kilograms (kg).

The client's weight is 154 lb.

Client weight (kg) = 154lb/2.2lb/kg

= 70kg.

Calculate the total dose to be administered (units).

The ordered dose is 200 units/kg.

Total dose (units) = 200units/kg×70kg

= 14,000units.

Calculate the volume to administer in milliliters (mL).

Available concentration is 25,000units/mL.

Volume (mL) = Totaldose(units)/Availableconcentration(units/mL)

= 14,000units/25,000units/mL

= 0.56mL.

Round the answer to the nearest tenth.

= 0.6mL.

A. Palpate the client's suprapubic area for distention. B. Instruct in effective techniques to cleanse the glans penis. C. Obtain a urine specimen for culture and sensitivity. D. Advise the client to maintain a voiding diary for one week.

Correct Answer is A

Explanation

A. Palpate the client's suprapubic area for distention: Palpating for bladder distention helps determine if urinary retention is present, which is common in older men with possible benign prostatic hyperplasia (BPH). Assessing retention is a priority because unresolved urinary obstruction can lead to hydronephrosis or kidney damage.

B. Instruct in effective techniques to cleanse the glans penis: Proper hygiene is important for preventing infection, especially in uncircumcised males, but it does not address the client’s primary problem of urinary retention and obstructive symptoms.

C. Obtain a urine specimen for culture and sensitivity: While urinary tract infections can occur in clients with urinary retention, the presenting symptoms here are more indicative of obstruction due to prostate enlargement. A culture may be ordered later, but not the first step.

D. Advise the client to maintain a voiding diary for one week: A voiding diary provides helpful long-term information about urinary patterns, but it does not address the acute issue of a bladder that may be distended and retaining urine.

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Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes dalteparin 200 units/kg subcutaneously once day for a client who weighs 154 pounds. The medication is available in 25,000 units/mL vial. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

Correct Answer is ["0.6"]

Explanation

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?

Correct Answer is A

Explanation

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