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.

Nursing Test Bank

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Correct Answer is A

Explanation

A. "I should use my wrist to test the temperature of the water before bathing": This is correct as using the wrist to test water temperature helps prevent burns or injuries, which is crucial for individuals with diabetes who may have reduced sensation in their feet.
B. "I should put lotion between my toes every day to prevent dryness and cracking": This is incorrect because applying lotion between the toes can promote fungal infections. Lotion should be applied to the tops and soles of the feet, avoiding the spaces between the toes.
C. "I should apply a heating pad to my feet every night to help with circulation": This is incorrect as heating pads can cause burns due to decreased sensation. It is safer to avoid direct heat applications.
D. "I should round the corners of my toenails with a nail file to prevent ingrown nails": This is incorrect; toenails should be trimmed straight across to prevent ingrown nails rather than rounded.

A. Leaning forward B. Prone C. Lithotomy D. Knees elevated

Correct Answer is A

Explanation

A. Leaning forward: This is correct as the client should be in a sitting position with arms resting on a table or a support to allow the lungs to expand and make the pleural space more accessible for the procedure.
B. Prone: This is incorrect because the prone position would not provide the necessary access to the pleural space and would be uncomfortable for the procedure.
C. Lithotomy: This is incorrect as the lithotomy position is used for gynecological procedures, not for thoracentesis.
D. Knees elevated: This is incorrect because elevating the knees is not a suitable position for thoracentesis and does not facilitate access to the pleural space.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about foot care with a client who has diabetes mellitus. Which of the following client statements indicates understanding of the teaching?

Correct Answer is A

Explanation

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?

Correct Answer is A

Explanation

A nurse is caring for a client who requires seizure precautions. Which of the following equipment should the nurse place at the client's bedside?

A nurse is reinforcing discharge teaching with a client regarding self-administration of regular insulin. Which of the following instructions should the nurse include?

A nurse is reviewing the medical record of a client who has hypertension and a new prescription for propranolol. Which of the following findings should the nurse identify as a contraindication for taking propranolol?

A nurse is collecting data from a client who is taking metoprolol. Which of the following findings should the nurse expect?

A nurse is collecting data from a client who had a bronchoscopy. Which of the following findings should the nurse report to the provider?

A nurse is preparing to obtain a postprandial blood glucose level from a client who has diabetes mellitus. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?