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 C

Explanation

A. Clean the client's finger with hexachlorophene: Hexachlorophene is not recommended for cleaning the skin before blood glucose testing; a mild soap and water or an alcohol swab is typically used.
B. Apply the first drop of blood to the test strip: The first drop of blood is often not used due to potential contamination; the nurse should usually wipe away the first drop and use the second one.
C. Hold the client's finger in a dependent position: This is correct as holding the finger downward can help increase blood flow to the fingertip, facilitating easier blood collection.
D. Prick the central tip of the client's finger: Pricking the central tip can be painful; the sides of the fingertip are preferred for less discomfort and to avoid nerve endings.

A. "You should focus on recovering from your cancer right now." B. "There are other ways to express intimacy besides intercourse." C. "I'm sure any partner will understand that you have no control over this." D. "The removal of a single testicle will not prevent you from having an erection."

Correct Answer is D

Explanation

A. "You should focus on recovering from your cancer right now.": This is incorrect because it dismisses the client's concerns about sexual function and does not address their immediate emotional and psychological needs.
B. "There are other ways to express intimacy besides intercourse.": This is a valid point, but it does not directly address the specific concern about maintaining sexual function, which the client may need to hear for reassurance.
C. "I'm sure any partner will understand that you have no control over this.": This is incorrect because it does not provide specific reassurance about the effects of the surgery on sexual function and can come across as dismissive.
D. "The removal of a single testicle will not prevent you from having an erection.": This is correct as the removal of one testicle does not generally impact the ability to achieve or maintain an erection, and it provides specific reassurance about sexual function.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

A nurse is caring for a young adult client who has testicular cancer and expresses concern about their sexual function following an orchiectomy of the involved testicle. Which of the following responses should the nurse make?

Correct Answer is D

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?

A nurse is preparing a client who has acute appendicitis for surgery. 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 collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?

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A nurse is collecting data from a client who is 8 hr postoperative following abdominal surgery. The client's blood pressure is 94/56 mm Hg. Which of the following actions should the nurse take first?