A nurse is assisting in the care of an older adult client who was admitted from a long-term care facility.

Admission Assessment 1400:

Client's history includes cigarette smoking for 50 years but quit 3 years ago, Parkinson's disease, and anxiety. Yesterday, client reported "feeling bad." Client is alert and oriented to self, reports upper chest discomfort, and is coughing up thick clear sputum.

Select the 3 findings that require immediate follow-up.

Oxygen saturation level

Tremors

Respiratory rate

Heart rate

Current level of consciousness

Chronic health condition

Answer and Explanation

Correct Answer : A,C,E

Since the client is experiencing upper chest discomfort and coughing up sputum, it is important to assess their oxygen saturation level. This finding can provide vital information about the client's respiratory status and the adequacy of their oxygenation.

The client's report of upper chest discomfort and coughing up thick clear sputum should prompt an assessment of their respiratory rate. Abnormal respiratory rates may indicate respiratory distress or compromise, which requires immediate attention.

Assessing the client's current level of consciousness is crucial, as any sudden changes in their mental status may indicate a serious underlying issue. Since the client has a history of Parkinson's disease and reported "feeling bad," it is important to evaluate their neurological status promptly.

The other options listed (tremors, heart rate, and chronic health condition) may also require follow-up, but they are not the most immediate concerns in this situation.

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Correct Answer is D

Explanation

A is incorrect because assessing the apical pulse while the newborn is crying can result in an inaccurate measurement due to increased heart rate and respiratory rate.
B is incorrect because palpating the radial pulse for 30 seconds is not appropriate for a newborn as it can be difficult to locate and count accurately.
C is incorrect because listening to the apical pulse while palpating the radial pulse is not necessary for a newborn and can be confusing and time-consuming.
D is correct because auscultating the apical pulse at least 1 min is the best way to assess a newborn's heart rate as it provides an accurate and reliable measurement.

A. Almonds. B. Bananas. C. Hazelnuts. D. Strawberries.

Correct Answer is B

Explanation

Choice A rationale:

Almonds are not typically associated with latex allergy or cross-sensitivity. Latex cross-reactivity is more commonly seen with certain fruits such as bananas, avocados, kiwis, and chestnuts.

Choice B rationale:

Bananas are known to be cross-reactive with latex allergy. Individuals allergic to latex are more likely to have allergies to certain fruits, including bananas. This cross-sensitivity occurs due to the structural similarity between latex proteins and proteins found in these fruits.

Choice C rationale:

Hazelnuts are not commonly associated with latex cross-reactivity. While some individuals with latex allergy may also be allergic to hazelnuts, it is not a high-risk food in the context of latex cross-sensitivity.

Choice D rationale:

Strawberries are not typically associated with latex allergy or cross-reactivity. Latex cross-reactivity is more commonly seen with fruits like bananas, avocados, kiwis, and chestnuts. Strawberries are not among the high-risk foods for individuals with latex allergy.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is performing an admission assessment of a school-age child who has spina bifida.The parent states that the child is allergic to latex.The nurse should assess further for cross-sensitivity to which of the following foods?

Correct Answer is B

Explanation

A nurse in a provider's office is monitoring the laboratory results of a client who has type 1 diabetes mellitus.Which of the following results indicates that the client demonstrates acceptable glycemic control?

A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. The first day of her last menstrual period (LMP) was May 8. According to Nägele's rule, which of the following dates should the nurse document as the client's estimated date of birth (EDB)?

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A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect?

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A nurse is admitting a client who has pneumonia. The nurse should initiate which of the following isolation precautions for the client?

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