The nurse is caring for a client.

Which of the following actions should the nurse take? Select all that apply.

Prepare for chest tube placement.

Ensure that the client has venous access.

Place the client in High Fowler's position.

Activate the rapid response team.

Administer fondaparinux as prescribed.

Administer midazolam as prescribed.

Answer and Explanation

Correct Answer : B,C,D,E

A. Prepare for chest tube placement: Chest tube placement is indicated for conditions like pneumothorax or pleural effusion, which are not clearly present in this scenario. Immediate interventions should focus on stabilizing the client and evaluating cardiopulmonary status first.

B. Ensure that the client has venous access: Establishing IV access is essential for rapid administration of medications, fluids, or emergency interventions if the client’s condition deteriorates. This is a priority in acute postoperative complications.

C. Place the client in High Fowler's position: Elevating the head of the bed improves lung expansion, reduces dyspnea, and enhances oxygenation in a client experiencing sudden respiratory distress and crackles, which may indicate pulmonary edema or fluid overload.

D. Activate the rapid response team: The client exhibits acute respiratory distress, hypoxemia, tachypnea, and cardiovascular changes. Activating the rapid response team ensures timely advanced intervention and evaluation to prevent further deterioration.

E. Administer fondaparinux as prescribed: Postoperative clients following total hip arthroplasty are at high risk for venous thromboembolism. Administering anticoagulant therapy, such as fondaparinux, helps prevent pulmonary embolism, which could be causing the client’s sudden dyspnea.

F. Administer midazolam as prescribed: Midazolam is a sedative and would not address the client’s acute respiratory distress. Sedation could worsen hypoxemia and respiratory compromise in this scenario.

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

Explanation

A. WBC count 22,000/mm³ (5,000 to 10,000/mm³): Leukocytosis is a common finding in appendicitis due to the inflammatory and infectious process. A significantly elevated WBC count supports the diagnosis and indicates the body’s response to infection.

B. Diarrhea: Diarrhea is not a typical manifestation of appendicitis. Clients more commonly present with constipation or localized abdominal pain rather than frequent loose stools, so this finding is not characteristic.

C. Rebound tenderness: Rebound tenderness, especially in the right lower quadrant, is a classic sign of peritoneal irritation associated with appendicitis. Pain that increases when pressure is released is a key physical examination finding.

D. Low-grade fever: A low-grade fever often accompanies appendicitis due to the body’s inflammatory response. Fever typically develops as the condition progresses and can help differentiate appendicitis from other causes of abdominal pain.

E. Hyperactive bowel sounds: Hyperactive bowel sounds are more commonly associated with gastroenteritis or early intestinal obstruction. In appendicitis, bowel sounds are often normal or decreased, particularly if peritoneal irritation is present.

A. Heart rate 190/min B. Irregular respirations C. Central cyanosis D. Temperature of 38.2° C (100.8° F)

Correct Answer is B

Explanation

A. Heart rate 190/min: A normal newborn heart rate ranges from 120 to 160 beats per minute. A heart rate of 190/min is tachycardic and is above the expected range for a healthy newborn.

B. Irregular respirations: Newborns often exhibit irregular respirations with periods of rapid breathing followed by pauses. This pattern is expected in the first few hours after birth and usually does not indicate distress if oxygen saturation is normal.

C. Central cyanosis: Central cyanosis, including blue lips or tongue, is abnormal and may indicate hypoxemia or congenital heart or respiratory issues. Normal newborns may show brief acrocyanosis of hands and feet but not central cyanosis.

D. Temperature of 38.2° C (100.8° F): A normal newborn temperature ranges from 36.5° C to 37.5° C (97.7° F to 99.5° F). A temperature of 38.2° C is elevated and may indicate infection or overheating.

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The nurse is caring for a client. Which of the following actions should the nurse take? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has appendicitis. Which of the following findings should the nurse identify as a manifestation of this condition? (Select all that apply.)

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

Explanation

A nurse is assessing a newborn 2 hr following birth. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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The nurse is caring for a client.

Which of the following actions should the nurse take? Select all that apply.