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A nurse is caring for a client.

Exhibit 1 Vital Signs 0800: Exhibit 2 Temperature 37.6° C (99.7° F) Blood pressure 108/56 mm Hg Heart rate 66/min Respiratory rate 18/min Pulse oximetry 97% on room air 0830: Temperature 37.5° C (99.5° F) Blood pressure 88/56 mm Hg Heart rate 104/min Respiratory rate 24/min Pulse oximetry 93% on room air Select the 4 findings that require immediate follow-up.

Temperature

Blood pressure

Respiratory rate

Pulse oximetry.

Heart rate.

Level of consciousness

Skin color and temperature

Answer and Explanation

Correct Answer : B,D,E

The blood pressure has dropped significantly from 108/56 mm Hg to 88/56 mm Hg.

The pulse oximetry has decreased from 97% to 93%, indicating a decrease in oxygen saturation.

The heart rate has increased from 66/min to 104/min.

The level of consciousness is always an important factor to monitor in a patient.

A. Temperature: The temperature has only changed slightly and is within the normal range.

C. Respiratory rate: The respiratory rate has increased but is still within normal range.

G. Skin color and temperature: This information is not provided in the exhibit.

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Correct Answer is B

Explanation

The nurse should respond to the client’s concern by saying “You are worried about having to wear a colostomy bag?” This response acknowledges the client’s concern and allows the client to express their feelings and concerns about the potential colostomy.

Choice A is not an appropriate response because it dismisses the client’s current concern and delays addressing it until after the surgery.
Choice C is not an appropriate response because it does not address the client’s concern about wearing a colostomy bag.
Choice D is not an appropriate response because it shifts the focus away from the client’s concern and onto someone else.

A. "No changes noted to the wound from previous nursing notes.". B. "New dressing applied as prescribed; no drainage on old dressing.". C. "The wound seems clean and does not appear to be infected.". D. "Client premedicated with MSO4 subq prior to dressing change.".

Correct Answer is B

Explanation

The nurse’s entry “New dressing applied as prescribed; no drainage on old dressing” demonstrates correct documentation because it includes specific details about the wound and the dressing change.
Choice A is wrong because it does not provide specific details about the wound or the dressing change.
Choice C is wrong because it includes subjective language (“seems” and “does not appear”) rather than objective observations.
Choice D is wrong because it only documents medication administration and does not provide any information about the wound or the dressing change.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has colon cancer and is scheduled for a colon resection with a possible colostomy tells the nurse, "I'm worried about that bag." Which of the following is an appropriate response by the nurse?

Correct Answer is B

Explanation

A nurse is documenting a dressing change for a client who has a pressure injury. Which of the following entries by the nurse demonstrates correct documentation?

Correct Answer is B

Explanation

A nurse is discussing the stages of general adaptation syndrome with a newly licensed nurse. The nurse should identify that which of the following manifestations occurs during the alarm reaction stage.

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