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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 A

Explanation

A. Monitor an IV infusion rate on an established schedule: This task is appropriate for a UAP because it involves observation and reporting rather than clinical decision-making. The UAP can ensure the IV is running at the prescribed rate and alert the nurse if any deviations occur.

B. Titrate oxygen to the prescribed parameters: Adjusting oxygen requires clinical judgment and assessment of respiratory status, including oxygen saturation and signs of hypoxia. This is a nursing responsibility and cannot be delegated to a UAP.

C. Insert a urinary catheter for an uncomplicated client: Catheter insertion is a sterile procedure that requires nursing knowledge and skill. Delegation to a UAP is not permitted due to the risk of infection and need for proper technique.

D. Procure platelet products from the blood bank: Obtaining blood products involves verification of patient identifiers, blood type, and compatibility, which are nursing responsibilities. This task requires clinical accountability and cannot be delegated to a UAP.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"E"}

Explanation

Rationale for correct choices:

• Cellulitis: The client presents with redness, warmth, swelling, and pain in the left lower leg, along with a small preceding cut. These findings are characteristic of cellulitis, a bacterial infection of the dermis and subcutaneous tissue, often following a breach in the skin barrier.

• Break in skin: The small cut noted above the lateral ankle provides an entry point for bacteria, explaining the localized infection. A break in skin is a common precursor to cellulitis, particularly in clients with diabetes or vascular compromise.

• Left lower leg erythema: Erythema indicates inflammation and infection, which are hallmark signs of cellulitis. The presence of erythema, along with swelling and warmth, supports the clinical diagnosis of a bacterial skin infection.

Rationale for incorrect choices:

• Left lower leg erythema (as a diagnosis option): Erythema alone describes a symptom rather than a medical diagnosis. While present, it does not capture the underlying bacterial infection requiring treatment.

• Break in skin (as a diagnosis option): A break in the skin is a risk factor or contributing event, not a formal diagnosis. It explains how infection occurred but does not replace the clinical diagnosis of cellulitis.

• Cool, pale left leg: This finding is more indicative of arterial insufficiency or ischemia rather than infection. The client’s affected leg is warm and erythematous, which contrasts with cool, pale tissue.

• Intact skin: Intact skin would not allow bacterial entry and does not explain the localized infection. The client has a visible small cut that preceded the erythema.

• Dry scaly skin: While common in peripheral vascular disease or chronic dermatologic conditions, dry scaly skin does not explain the acute signs of infection seen in this client.

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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

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Correct Answer is A

Explanation

Patient Data Exhibits Choose the most likely options for the information missing from the statement below by selecting from the lists of options provided. The nurse recognizes that a diagnosis ofdropdown would be explained by assessment findings of dropdown anddropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"E"}

Explanation

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Patient Data Exhibits Click to indicate which education instructions the nurse should include to prevent future cellulitis and promote healing when preparing the client for discharge. Each column must have at least one response selected.

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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.