When inspecting the client’s skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client’s history requires additional follow-up by the nurse?

Works in a day care center.

Adheres to a gluten-free diet.

Takes an oral anticoagulant.

Recently had dental surgery.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Working in a day care center may expose the client to minor injuries or infections, but it is not directly associated with widespread ecchymosis. Ecchymosis is more likely related to systemic issues rather than occupational hazards.
Choice B rationale
Adhering to a gluten-free diet is typically related to managing celiac disease or gluten intolerance, which primarily affects the gastrointestinal tract. Ecchymosis is not a typical manifestation of gluten intolerance.
Choice C rationale
Taking an oral anticoagulant medication increases the risk of bleeding, which can manifest as ecchymosis (bruising) on the skin. Anticoagulants such as warfarin or aspirin can interfere with the blood’s ability to clot, leading to bleeding into the skin and subsequent ecchymosis.
Choice D rationale
Dental surgery may involve procedures that could cause minor trauma to the oral tissues, leading to localized bruising around the mouth or jaw area. However, this localized bruising would typically not explain the presence of ecchymosis observed on the trunk and extremities.

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Correct Answer is B

Explanation

A. Document the presence of borborygmi.Loud, high-pitched, and almost continuous gurgling sounds can indicate borborygmi.However, the nurse should not immediately document without fully assessing all four quadrants to ensure a comprehensive evaluation of bowel sounds.

B. Auscultate the remaining quadrants.A complete assessment of bowel sounds involves auscultating all four quadrants to determine if the sounds are generalized, localized, or absent in other areas. This provides a more accurate assessment of the client’s gastrointestinal function.

C. Elevate the head of the client’s bed immediately.The client’s position does not typically affect bowel sounds, and elevating the head of the bed is unnecessary unless the client has difficulty breathing or other non-gastrointestinal concerns.

D. Use the bell of the stethoscope to auscultate again.Using the bell, which is intended for low-pitched sounds like bruits or heart murmurs, would not provide any additional relevant information.

A. Administer oxygen via nasal cannula. B. Obtain a sputum culture. C. Administer an antipyretic medication. D. Encourage the client to increase fluid intake.

Correct Answer is A

Explanation

Choice A Rationale: Administeíing oxygen via nasal cannula is the fiíst píioíity in this scenaíio. ľhe client’s oxygen satuíation is 88% on íoom aií, which indicates hypoxemia. Píoviding supplemental oxygen will help impíove the client’s oxygenation and alleviate symptoms of shoítness of bíeath. Ensuíing adequate oxygenation is cíucial to píevent fuítheí íespiíatoíy distíess and potential complications.
Choice B Rationale: Obtaining a sputum cultuíe is impoítant to identify the causative oíganism of the client’s íespiíatoíy infection and guide appíopíiate antibiotic theíapy. Howeveí, this action is not the immediate píioíity. Addíessing the client’s hypoxemia by administeíing oxygen takes píecedence to stabilize the client’s condition.
Choice C Rationale: Administeíing an antipyíetic medication can help íeduce the client’s feveí and impíove comfoít. Howeveí, this is not the immediate píioíity. ľhe client’s hypoxemia and íespiíatoíy distíess need to be addíessed fiíst by administeíing oxygen.
Choice D Rationale: Encouíaging the client to incíease fluid intake is impoítant foí maintaining hydíation and helping to thin íespiíatoíy secíetions. Howeveí, this action is not the immediate píioíity. ľhe client’s hypoxemia and íespiíatoíy distíess need to be addíessed fiíst by administeíing oxygen.

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When inspecting the client’s skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client’s history requires additional follow-up by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high-pitched almost continuous gurgling in two quadrants. Which action should the nurse implement first?

Correct Answer is B

Explanation

A nurse is caring for a 65-year-old male client in the clinic who presents with shortness of breath and a productive cough. The client has a history of smoking and was recently treated with antibiotics for pneumonia. Exhibits Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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