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Patient Data

Exhibits

Which laboratory test(s) would be helpful in determining the plan of care (POC) for this client? Select all that apply.

Complete blood count

Arterial blood gas

Type and screen

Coagulation studies

Electrolytes

Blood culture

Urine osmolality

Lipid panel

Answer and Explanation

Correct Answer : A,B,C,D,E

A. Complete blood count: A CBC is essential to evaluate hemoglobin and hematocrit levels, which can indicate the severity of blood loss from abdominal trauma. It also helps monitor for anemia or infection risk in this critical setting.

B. Arterial blood gas: An ABG provides information about oxygenation, ventilation, and acid–base balance, which are crucial for a trauma client on mechanical ventilation. It guides adjustments in ventilator settings and assesses for shock-related metabolic acidosis.

C. Type and screen: Given the evidence of internal bleeding and hypotension, a blood transfusion may be necessary. A type and screen ensures blood products can be matched and made available quickly in case of massive transfusion.

D. Coagulation studies: Trauma and massive transfusion can lead to coagulopathy. PT, INR, and aPTT results help guide interventions such as plasma or platelet administration, ensuring proper clotting function during surgery and recovery.

E. Electrolytes: Monitoring electrolytes is important because fluid resuscitation, blood loss, and shock can cause significant imbalances, such as hypokalemia or metabolic derangements, which can complicate management.

F. Blood culture: Blood cultures are obtained when infection or sepsis is suspected. This client’s presentation is acute trauma-related hemorrhage, not infection, so this test is not immediately useful.

G. Urine osmolality: This test is used to evaluate renal concentrating ability and fluid balance, but it is not a priority in acute trauma. Immediate fluid and blood replacement are the focus.

H. Lipid panel: A lipid panel assesses long-term cardiovascular risk, not acute trauma or hemorrhage. It has no role in the immediate plan of care for this client.

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Correct Answer is B

Explanation

A. Abdominal cramping: Mild to moderate abdominal cramping is a common symptom of acute gastritis and may not indicate a complication. While it should be monitored, it is not typically an emergency sign.

B. Bloody emesis: Vomiting blood may indicate gastrointestinal bleeding, a serious complication of acute gastritis. Immediate reporting is essential to prevent significant blood loss and allow prompt medical intervention.

C. Low grade fever: A mild fever can accompany gastritis due to inflammation or infection but is not usually life-threatening. It should be monitored but does not require urgent reporting unless it worsens.

D. Bruising of the skin: Easy bruising is not a typical manifestation of gastritis and is not directly related to acute gastrointestinal complications. It may suggest another underlying condition but is not the priority concern for this client.

A. Ensure that the restraints are snug against the client's wrists. B. Move the ties so the restraints are secured to the side rails. C. Ensure that the knot can be quickly released. D. Tie the knot with a double turn or square knot.

Correct Answer is C

Explanation

A. Ensure that the restraints are snug against the client's wrists: Restraints should be snug enough to prevent injury but not so tight as to impair circulation. However, this does not address the safety concern related to the type of knot used.

B. Move the ties so the restraints are secured to the side rails: Restraints should never be tied to the side rails because this can cause injury if the rail moves or the client attempts to climb over it.

C. Ensure that the knot can be quickly released: Using a quick-release knot, such as a half bow or slip knot, is essential to ensure the nurse can rapidly remove the restraints in an emergency, such as sudden respiratory distress or circulatory compromise.

D. Tie the knot with a double turn or square knot: Square knots are secure but not quick to release. In contrast, safety guidelines recommend quick-release knots for client restraints to allow for prompt intervention.

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Patient Data Exhibits Which laboratory test(s) would be helpful in determining the plan of care (POC) for this client? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?

Correct Answer is B

Explanation

Before leaving the room of a client who is confused, the nurse observes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. Which action should the nurse take before leaving the room?

Correct Answer is C

Explanation

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An adult client was diagnosed with stage IV lung cancer three weeks ago. The client's spouse approaches the nurse and asks, "How will I know that my husband's death is imminent? Our two adult children want to be here when their father dies." Which is the best response by the nurse?

Patient Data

Exhibits

Which laboratory test(s) would be helpful in determining the plan of care (POC) for this client? Select all that apply.