PPH may be sudden and result in rapid blood loss.
The nurse must be alert to the symptoms of hemorrhage and hypovolemic shock and be prepared to act quickly to minimize blood loss.
Astute assessment of circulatory status can be done with noninvasive monitoring.
Please match the type of noninvasive assessment that the RN would perform with the appropriate clinical manifestation or body system:.
Pulse oximetry.
Heart sounds.
Arterial pulses
Skin color, temperature, turgor.
Presence or absence of anxiety.
The Correct Answer is E
The presence or absence of anxiety is a noninvasive assessment that the RN would perform to evaluate the patient’s psychological status and possible signs of hypovolemic shock.
Anxiety can indicate reduced cerebral perfusion due to blood loss and low blood pressure.
Choice A is wrong because pulse oximetry is a noninvasive assessment that the RN would perform to measure the oxygen saturation of the patient’s blood, not the circulatory status.
Choice B is wrong because heart sounds are a noninvasive assessment that the RN would perform to auscultate the cardiac rhythm and rate of the patient, not the circulatory status.
Choice C is wrong because arterial pulses are a noninvasive assessment that the RN would perform to palpate the strength and quality of the patient’s peripheral pulses, not the circulatory status.
Choice D is wrong because skin color, temperature, and turgor are noninvasive assessments that the RN would perform to observe the skin integrity and hydration of the patient, not the circulatory status.
Normal ranges for pulse oximetry are 95% to 100%, for heart rate are 60 to 100 beats per minute, and for blood pressure are 120/80 mmHg.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A way to establish rapport. Doing a simple magic trick using gauze is a way to gain the child’s trust and attention, and to make the dressing change less stressful and more fun. This is appropriate for a 5-year-old child who is in the stage of initiative versus guilt according to Erikson’s theory of psychosocial development.
Choice A is wrong because 5-year-old children are curious and imaginative, and they enjoy magic tricks and fantasy play.
Choice C is wrong because a simple magic trick is not too distracting, but rather a way to engage the child and reduce anxiety.
Choice D is wrong because a simple magic trick is not inappropriate due to the child’s cognitive development. According to Piaget’s theory of cognitive development, 5-year-old children are in the preoperational stage, which means they can use symbols and language to represent objects and events.
A magic trick using gauze is a symbolic representation of something else, which the child can understand and appreciate.
Correct Answer is D
Explanation
Diabetes insipidus is a disorder of the posterior pituitary gland that causes a deficiency of antidiuretic hormone (ADH). This leads to excessive urination (polyuria) and excessive thirst (polydipsia) as the body tries to balance the fluid loss. These symptoms may be so severe that the child does little other than drink and urinate.
Choice A is wrong because oliguria means decreased urine production and is not associated with diabetes insipidus.
Choice B is wrong because glycosuria means glucose in the urine and is associated with diabetes mellitus, not diabetes insipidus.
Choice C is wrong because nausea and vomiting are associated with inappropriate ADH secretion (SIADH), which causes fluid retention and hyponatremia, not diabetes insipidus.
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