The nurse is caring for a patient in hypovolemic shock as a result of penetrating thoracic trauma. The patient has received 3L of lactated ringers' solution (LR), 2 units of packed red blood cells (PRBCs), 1 unit of fresh frozen plasma (FFP), and 1 unit of platelets. Which assessment finding should the nurse report to the provider immediately?

Blood pressure 102/78

Pulse oximetry 95%

Crackles at bilateral bases

Heart rate 105 beats per minute

Answer and Explanation

The Correct Answer is C

A) Blood pressure 102/78:
This blood pressure is within an acceptable range, especially after resuscitation with fluids and blood products. While hypotension is a concern in hypovolemic shock, this blood pressure is stable and does not indicate an immediate need for intervention. Blood pressure monitoring is essential, but this finding is not as urgent as other options.

B) Pulse oximetry 95%:
A pulse oximetry reading of 95% is generally considered within normal limits for a patient who has undergone resuscitation and is stable. Oxygen saturation levels should be monitored, but this finding does not indicate an immediate need for intervention. Values below 90% would be more concerning, especially in trauma patients, but 95% is acceptable.

C) Crackles at bilateral bases:
The presence of crackles at the bilateral lung bases is a sign of pulmonary edema, which can occur as a result of fluid overload, especially after aggressive resuscitation with fluids like lactated Ringer's solution (LR) and blood products. In hypovolemic shock, rapid infusion of fluids can overwhelm the heart's ability to handle the volume, leading to fluid accumulation in the lungs. This finding is concerning because it can indicate a shift from hypovolemic shock to a state of volume overload, which can worsen respiratory function and lead to acute respiratory distress syndrome (ARDS).

D) Heart rate 105 beats per minute:
A heart rate of 105 beats per minute is slightly elevated but can be expected in a patient who has experienced trauma and is undergoing fluid resuscitation. Tachycardia is often seen in hypovolemic shock as the body compensates for decreased circulating volume. While monitoring the heart rate is important, this finding does not indicate an immediate life-threatening concern compared to crackles in the lungs, which suggest pulmonary edema.

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Correct Answer is D

Explanation

A) Isolate away from the family in a separate room:
Isolation is unnecessary for a client with HIV. HIV is primarily transmitted through specific bodily fluids such as blood, semen, vaginal fluids, and breast milk. The virus is not transmitted through casual contact, so there is no need for the client to isolate from their family.

B) Retest for opportunistic infections monthly:
While it is important for clients with HIV to be regularly monitored for opportunistic infections, monthly testing is not typically necessary unless specific symptoms or clinical indicators warrant it. Routine follow-up with a healthcare provider to monitor CD4 count, viral load, and overall health status is essential, but frequent opportunistic infection screening is not a general requirement.

C) Live alone to prevent any transmission of HIV:
There is no need for individuals with HIV to live alone to prevent transmission. As mentioned earlier, HIV is not spread through casual contact, so the client can live with family members without concern, as long as they follow proper precautions regarding handling blood or bodily fluids.

D) Clean any of their blood that spills with bleach:
Blood and other bodily fluids containing HIV are the primary sources of transmission. If any blood spills, cleaning the area with bleach (a disinfectant known to destroy HIV) is an important safety measure to reduce the risk of transmission. The client should also be taught to use gloves when cleaning blood spills, and to follow universal precautions when handling items contaminated with blood or other potentially infectious fluids.

A. be placed in isolation to prevent radiation exposure to others B. avoid consuming any food or fluids for 24 hours prior to the treatment C. avoid all physical activity for six weeks after the treatment D. discontinue all other medications for a week before the treatment

Correct Answer is A

Explanation

A) Be placed in isolation to prevent radiation exposure to others:
Radioactive iodine (I-131) is commonly used to treat thyroid cancer because it targets and destroys thyroid tissue, including any remaining cancerous cells. This treatment involves the administration of a radioactive substance that can be excreted through saliva, urine, and sweat. To minimize radiation exposure to others, patients are often placed in isolation, particularly in a hospital setting, for a period following administration.

B) Avoid consuming any food or fluids for 24 hours prior to the treatment:
While it’s essential for patients to follow specific instructions regarding food and fluid intake, such as avoiding certain foods or fluids that may interfere with absorption or increase the risk of side effects (like dairy products), the patient does not need to avoid all food and fluids for 24 hours after receiving radioactive iodine.

C) Avoid all physical activity for six weeks after the treatment:
While some precautions, such as avoiding close contact with others for a short period of time, may be necessary, avoiding physical activity for six weeks is not usually required. Patients may be advised to take it easy during the initial recovery phase, but they can typically resume normal activities once the initial isolation period is complete and their radiation exposure is below safety thresholds.

D) Discontinue all other medications for a week before treatment:
However, certain medications that affect thyroid function (such as thyroid hormones or antithyroid medications) may need to be adjusted or stopped before treatment to ensure the effectiveness of the radioactive iodine. The specifics would depend on the patient’s condition and the healthcare provider’s instructions.

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Naxlex Comprehensive Predictor Exams

A nurse is providing care with for a client diagnosed with human immunodeficiency virus. The client discusses concerns about transmitting the virus to their family members. What should the nurse include in client education? The nurse teaches the client to:

Correct Answer is D

Explanation

The nurse should implement which safety consideration for a patient when administering oral radioactive iodine for thyroid cancer? The patient should:

Correct Answer is A

Explanation

The nurse is preparing discharge teaching for a client newly diagnosed with cancer who just had a tunneled IV catheter (Hickman) placed. The nurse would include which information in the teaching plan regarding sign and symptoms of infection?

The nurse understands the primary assessment for a patient following a major trauma:

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The nurse is teaching a client about seeking medical attention for suspected melanoma skin cancer lesions. The client would demonstrate to the nurse an understanding of teaching by stating "1 will seek medical attention if the mole has:

A client diagnosed with a stroke complains of a severe headache. Which intervention would be the nursing priority?

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