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Review H and P and nurses’ notes.

Exhibits

Click to highlight which assessment findings should the nurse attend to right away?

Admitted client. Vital signs: heart rate 128 beats/minute, rhythm sinus tachycardia, respiratory rate 14 breaths/minute, oxygen saturation 100% on 40% fraction of inspired oxygen, temperature 96.9° F (36.1° C), blood pressure 90/79 mm Hg. Pulse pressure calculated to be less than 40 mm Hg. The client's surgical dressing is clean and dry. Ecchymosis noted on the abdomen around the dressing. The client has a peripheral intravenous 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 rate 128 beats/minute

rhythm sinus tachycardia

respiratory rate 14 breaths/minute

oxygen saturation 100% on 40% fraction of inspired oxygen

temperature 96.9° F (36.1° C)

blood pressure 90/79 mm Hg

surgical dressing is clean and dry

Ecchymosis noted on the abdomen around the dressing

Answer and Explanation

The Correct Answer is ["A","B","E","F","H"]

Heart Rate: 128 beats/min (Sinus Tachycardia): Sinus tachycardia can be a compensatory response to hypovolemia, internal bleeding, or pain. Given the liver and spleen lacerations identified on the CT scan and blood in the peritoneum, tachycardia may indicate ongoing hemorrhage or hypoperfusion.

Blood Pressure: 90/79 mmHg (Narrow Pulse Pressure): A pulse pressure of less than 40 mmHg suggests inadequate perfusion and possible hemorrhagic shock. The systolic blood pressure (90 mmHg) is at the lower limit of normal, but the diastolic pressure (79 mmHg) is elevated, which can indicate compensatory vasoconstriction due to hypovolemia. Immediate fluid resuscitation or blood transfusion may be required to prevent worsening shock.

Temperature: 96.9°F (36.1°C): Trauma clients, especially those with hemorrhage, are at risk for trauma triad of death (hypothermia, acidosis, coagulopathy) due to massive fluid shifts and blood loss. Even mild hypothermia can impair coagulation and worsen bleeding, requiring active warming measures (e.g., warm IV fluids, heated blankets).

Abdominal Ecchymosis and Hematoma: Significant bruising around the surgical dressing suggests ongoing internal bleeding or vascular injury.

Close monitoring is needed to assess for expanding hematoma, increased abdominal distension, or hemodynamic instability.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"C"}}

Explanation

Bruises in various stages of healing: This often indicates physical abuse, as it suggests trauma or injury from external force.

Over-sedation: This could be indicative of physical abuse if it is intentional or misuse of medications.

Depression or withdrawn behavior: These can be signs of neglect, as they may result from a lack of emotional support or social interaction.

Leaving an older adult in a public space: This is a clear indicator of abandonment, as it shows neglect of the individual's safety and well-being.

Untreated pressure injuries: These are signs of neglect, reflecting a failure to provide adequate care and prevent injuries.

Poor personal hygiene: Often a result of neglect, indicating a lack of attention to the individual's basic needs and self-care.

A. The client voluntarily grants permission for the procedure to be done. B. The client understands the risks and benefits associated with the procedure. C. The client is competent to sign the consent without impairment of judgment. D. Verifies that the client understands the procedure that is being performed. E. The surgeon has explained to the client why the surgery is necessary.

Correct Answer is ["A","C"]

Explanation

A: The nurse’s signature as a witness indicates that the client voluntarily signed the consent form, free from coercion.

B: The nurse is not responsible for explaining the risks and benefits of the surgery; that is the surgeon's role.

C: The nurse’s signature also affirms that the client appears competent to sign the consent and is not under any impairment or duress at the time of signing.

D: The nurse does not verify that the client understands the procedure, but simply observes that the consent is signed willingly.

E: The surgeon, not the nurse, is responsible for explaining the procedure and its necessity to the client.

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Naxlex Comprehensive Predictor Exams

Exhibits The nurse suspects elder mistreatment. Click to indicate if the listed manifestation of abuse is consistent with physical abuse, abandonment, or neglect. Each row must have only one response option selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"C"}}

Explanation

After the nurse witnesses a preoperative client signing the surgical consent form, the nurse signs the form as a witness. Which is (are) the legal implication(s) of the nurse's signature on the client's surgical consent form? Select all that apply.

Correct Answer is ["A","C"]

Explanation

Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. Which action should the nurse take?

A client's catheter bag was left on the client's bed for a prolonged period of time, and the client develops a urinary tract infection (UTI). In evaluating the cause of the infection, which should the nurse identify as the infection reservoir?

A client expresses concern about receiving proper care in accordance with the client's religion. Which action is best for the nurse to take?

A client newly diagnosed with diabetes mellitus suddenly becomes confused and weak. Which intervention(s) should the nurse implement? Select all that apply.

One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in this client's plan of care?

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

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