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. Sickle cell anemia typically presents with hemolytic crises and sickle-shaped red blood cells, not necessarily heavy menstrual bleeding.
B. Folic acid deficiency anemia can cause macrocytic anemia but is less likely to cause heavy menstrual bleeding as the primary symptom.
C. Pernicious anemia is due to vitamin B12 deficiency and typically presents with neurological symptoms along with anemia, not necessarily heavy menstrual bleeding.
D. Iron-deficiency anemia commonly presents with weakness, fatigue, and heavy menstrual bleeding due to inadequate iron for red blood cell production.

A. Urine output of175 mL in the past 8 hr B. Urine output of 2,200 mL in the past 24 hr C. First-voided urine in the morning has a strong odor D. Urine is cloudy after sitting in the urinal for 6 hr

Correct Answer is A

Explanation

A. Urine output of 175 mL in the past 8 hours is significantly low and indicates potential acute kidney injury or worsening renal function, requiring immediate notification to the provider.
B. Urine output of 2,200 mL in the past 24 hours is within normal limits.
C. Strong odor in the first-voided urine in the morning is common and not necessarily indicative of a problem.
D. Cloudy urine after sitting in the urinal for several hours can occur due to crystallization or bacterial growth and is not a critical finding.

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

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a young female adult client who reports weakness, fatigue, and heavy menstrual periods. The client has a hemoglobin level of 8 g/dL and a hematocrit level of 28 g/dL. The nurse suspect which of the following types of anemia?

Correct Answer is D

Explanation

A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider?

Correct Answer is A

Explanation

A nurse is teaching a group of newly licensed nurses on effective techniques for counseling clients about sexually transmitted infections (STIs). Which of the following statements should the nurse include in the teaching?

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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.)

A nurse in the medical-surgical unit is assigning client care to a nurse who is floating from the PACU. The nurse should recognize that the float nurse is most qualified to care for which of the following clients?

A nurse is preparing to administer penicillin IM to an adult client. Which of the following angles should the nurse use for injection into the client's ventrogluteal muscle?

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A nurse is teaching a client who has a new diagnosis of atopic dermatitis. Which of the following statements should the nurse include in the teaching?

A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse?

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