36. A nurse is caring for a client.
Exhibits
Which of the following findings at 1015 requires further action?

(Select all that apply.)

Low back pain

Urine color

Blood pressure

Respiratory rate

Answer and Explanation

Correct Answer : C,D

A.   While low back pain can be concerning, it's not an immediate priority compared to the vital sign changes. However, the nurse should document the pain and ask about its characteristics.
B.   Brown-colored urine can sometimes indicate dehydration or certain medical conditions, requiring follow-up.
C.   A significant drop in blood pressure (74/50 mmHg) indicates hypotension and requires immediate attention.
D.   An increase in respiratory rate (28 breaths/min) suggests the client may be experiencing respiratory distress and needs evaluation.
E.   The client’s oxygen saturation is 95% on room air which is normal.

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Correct Answer is D

Explanation

A. Difficulty moving the upper extremities may be a result of the stroke but is not a direct complication of immobility.
B. Difficulty hearing some types of sounds is not a typical complication of immobility.
C. Stiffness in the lower extremities can occur but is less urgent than skin breakdown.
D. A reddened area over the sacrum indicates pressure injury, a common and serious complication of immobility that requires immediate attention.

A. A client who requests to obtain information on the adverse effects of antidepressant medication therapy. B. A client who requests to get school assignments while hospitalized on a pediatric unit. C. A client who requests to secure an emergency notification system in the home. D. A client who requests to receive additional instructions on breastfeeding prior to discharge. E. A client who requires placement in an assisted living facility.

Correct Answer is ["B","C","E"]

Explanation

A. Providing information on medication effects is within the nurse's scope of practice and does not typically require social work involvement.
B. Client B, who is hospitalized and wishes to keep up with school assignments, may need assistance with educational continuity plans.
C. Securing an emergency notification system involves social services to assess and arrange appropriate services.
D. Providing breastfeeding instructions is part of nursing care and does not typically require social work involvement.
E. Placement in an assisted living facility requires social work assistance to coordinate appropriate care and transition.

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36. A nurse is caring for a client. Exhibits Which of the following findings at 1015 requires further action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility?

Correct Answer is D

Explanation

A nurse is caring for a group of clients. Which of the following clients should the nurse refer to a social worker? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse is providing teaching to a client who has rheumatoid arthritis and a new prescription for methotrexate. Which of the following information should the nurse provide?

A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply.)

A nurse is reviewing the medical record of a client who has a potassium level of 3.0 mEq/L. Which of the following findings should the nurse recognize as a potential causative factor?

A nurse is planning care for a client who has idiopathic thrombocytopenic purpura (ITP). Which of the following manifestations is most appropriate for the nurse to monitor?

A nurse on the medical-surgical unit is conducting a fall risk assessment for four clients. The nurse should identify that which of the following clients is the greatest risk for a fall?

A nurse in an emergency department (ED) is admitting a client. Exhibits Select 4 findings in the client's medical record that place them at risk for pneumonia.

A nurse is planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan?

36. A nurse is caring for a client.
Exhibits
Which of the following findings at 1015 requires further action?