The nurse is continuing to assist in the care of the client.
Exhibits
For each data collection finding, click to specify if the finding on postoperative day 1 is consistent with hypovolemic shock or pulmonary embolism. Each finding may support more than 1 disease process or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.

Heart rate

Respiratory effort

Pain

Blood pressure

Mentation

Answer and Explanation

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

Heart rate
•   Hypovolemic Shock
o   The elevated heart rate of 104/min is consistent with hypovolemic shock, where the body compensates for reduced blood volume by increasing heart rate to maintain cardiac output and perfusion.
•   Pulmonary Embolism
o   An increased heart rate can also occur with pulmonary embolism as the body responds to decreased oxygenation and impaired cardiac function.
Respiratory effort
•   Hypovolemic Shock
o   Increased respiratory rate of 24/min may be a compensatory mechanism in hypovolemic shock to enhance oxygen delivery to tissues despite reduced blood volume.
•   Pulmonary Embolism
o   Elevated respiratory rate can also be seen in pulmonary embolism due to impaired gas exchange and increased respiratory effort to compensate for decreased oxygen levels.
Pain
•   Pulmonary Embolism
o   Pain, particularly pleuritic chest pain, is a common symptom of pulmonary embolism and could be indicative of embolic obstruction in the pulmonary circulation.
Blood pressure
•   Hypovolemic Shock
o   The drop in blood pressure to 88/54 mm Hg is consistent with hypovolemic shock, where reduced blood volume leads to decreased perfusion and hypotension.
Mentation
•   Hypovolemic Shock
o   Altered mentation, such as restlessness or agitation, can be a sign of hypovolemic shock as decreased perfusion affects brain function and consciousness.
•   Pulmonary Embolism
o   Changes in mentation can also occur in pulmonary embolism due to hypoxemia or decreased perfusion to the brain.

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Correct Answer is B

Explanation

A. Orthopneic: This position is used for clients with respiratory distress and is not suitable for sigmoidoscopy.
B. Knee-chest: This is correct as the knee-chest position is commonly used for sigmoidoscopy to provide optimal access to the rectum and sigmoid colon.
C. Trendelenburg: This position, with the head lower than the feet, is typically used for shock or hypotension, not for sigmoidoscopy.
D. Prone: The prone position is not appropriate for sigmoidoscopy as it does not allow adequate access to the rectum and sigmoid colon.

A. Close the doors to the room and to the bathroom. B. Assist the client to a nearby common area. C. Activate the fire alarm system. D. Use a fire extinguisher at the source of the smoke.

Correct Answer is B

Explanation

A. Close the doors to the room and to the bathroom: This helps to contain the smoke but does not address the immediate danger of the smoke.
B. Assist the client to a nearby common area: This is correct as ensuring the safety of the client is the top priority. The client should be moved to a safer location away from the smoke.
C. Activate the fire alarm system: This is important for alerting others to the fire but does not directly address the immediate danger to the client.
D. Use a fire extinguisher at the source of the smoke: This can be done after ensuring the client's safety, as the primary concern is to remove the client from potential harm.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing a client for a sigmoidoscopy. In which of the following positions should the nurse place the client?

Correct Answer is B

Explanation

A nurse enters a client's room and sees smoke coming from the bathroom. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is reinforcing teaching about home safety measures with a client who is visually impaired. Which of the following instructions should the nurse include?

A nurse is assisting with the preparation of a client who is scheduled for a thoracentesis. In which of the following positions should the nurse place the client during the procedure?

A nurse is caring for a client who had a stroke and is experiencing dysphagia. Which of the following actions should the nurse take when assisting the client to eat?

A nurse is reinforcing teaching with an older adult client about preventing osteoporosis. Which of the following recommendations should the nurse make?

A nurse is assisting in the care of a client whose cardiac monitor suddenly displays ventricular tachycardia. Which of the following is the priority nursing action?

A nurse is assisting with postoperative care of a client who had surgery for creation of a colostomy 24 hr ago. Which of the following findings should the nurse report to the provider?