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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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Assist client to a supine position: The initial step in assessing orthostatic hypotension is to have the client lie supine for several minutes. This allows baseline blood pressure and heart rate to be measured in a stable, resting position before changing posture.

B. Instruct the client to stand upright: Standing too soon without establishing baseline measurements may place the client at risk for falls or injury due to dizziness or sudden blood pressure changes.

C. Place the client in a semi-Fowler's position: A semi-Fowler’s position is partially upright, which does not provide an accurate baseline for assessing orthostatic changes compared to the supine position.

D. Help the client sit on the side of the bed: Sitting at the bedside is part of the assessment sequence, but it should occur after obtaining supine baseline readings to safely monitor changes in blood pressure and heart rate.

A. Absent sounds. B. Pain. C. Musical and drumlike. D. Tenderness. E. Auscultate for presence of bilateral breath sounds.

Correct Answer is C

Explanation

A. Absent sounds: Absent bowel sounds are abnormal and may indicate an ileus, obstruction, or decreased intestinal motility, requiring further assessment.

B. Pain: Pain elicited during percussion is not a normal finding and may indicate underlying pathology such as inflammation, infection, or organ enlargement.

C. Musical and drumlike: Tympany, which produces a musical, drumlike sound during percussion, is a normal finding over air-filled structures in the abdomen. It indicates the presence of gas in the stomach and intestines, reflecting normal gastrointestinal function.

D. Tenderness: Tenderness on percussion is abnormal and may suggest inflammation, infection, or other abdominal pathology requiring further evaluation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older client reports experiencing frequent dizzy spells. To assess for orthostatic hypotension, which action should the nurse take first?

Correct Answer is A

Explanation

The nurse completes percussion of the abdomen on an older adult client. Which finding is considered normal for this client?

Correct Answer is C

Explanation

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The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?