Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for a client in a clinic.

Exhibits

Based on the information in the client's medical record, which of the following findings require immediate follow-up?

Select the 4 findings that require follow-up.

Client experiences nightmares

Heart rate 99/min

Attends school regularly

Smoking marijuana to clear their mind

Startles easy during thunderstorm Witnessing their family's death

BP 122/80 mm Hg

Caregiver reporting client acting differently than usual

Answer and Explanation

Correct Answer : A,D,E,G

A.   The client's nightmares could be indicative of post-traumatic stress disorder (PTSD), especially after the client’s parents and a sibling passed away from injuries sustained when a tornado moved through their town 1 month ago.
B.   A heart rate of 99/min is within the normal range for the client’s age and requires no need for follow-up.
C.   While regular attendance at school is generally considered a positive behavior, it does not directly indicate a need for immediate follow-up. However, it is relevant information for assessing the client's overall functioning and resilience in the context of their recent traumatic experience.
D.   The client's use of marijuana as a coping mechanism raises concerns about their mental health and potential substance abuse. Immediate follow-up is needed to address this issue and provide appropriate support and intervention.
E.   Startles easily during thunderstorms and witnessing their family's death are findings that indicate symptoms of post-traumatic stress disorder (PTSD) or acute stress reaction following the traumatic event of witnessing their family's death. Immediate follow-up is

necessary to assess the client's mental health status and provide appropriate support and counseling.
F.   A blood pressure of 122/80 mm Hg falls within the normal range for adolescents and does not indicate an immediate medical concern. While blood pressure monitoring is important for overall health assessment, this finding alone does not warrant immediate follow-up in the context of the client's presenting issues.
G.   The caregiver's observation that the client is acting differently than usual suggests a change in behavior or mental health status that requires further assessment and intervention. Immediate follow-up is needed to explore the caregiver's concerns and address any underlying issues affecting the client's well-being

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

To calculate the IV infusion rate for dopamine hydrochloride, we first need to convert the dose from micrograms per kilogram per minute (mcg/kg/min) to milligrams per hour (mg/hr). The patient weighs 80 kg and the prescribed dose is 4 mcg/kg/min.

First, calculate the dose in mcg/hr: 4 mcg/kg/min x 80 kg x 60 min/hr = 19200 mcg/hr.

Next, convert mcg to mg: 19200 mcg/hr / 1000 mcg/mg = 19.2 mg/hr.

We have an 800 mg dopamine hydrochloride solution in a 250 mL bag. To find out how many mL/hr to administer, we use the following proportion:

(800 mg / 250 mL) = (19.2 mg / X mL).

Solving for X gives us X = (19.2 mg * 250 mL) / 800 mg, which equals 6 mL/hr.

Therefore, the nurse should set the IV infusion pump to deliver 6 mL/hr.

A. Monitor the client's vital signs every 12 hr. B. Inspect the client's mouth every 8 hr. C. Provide fresh fruit with the client's meals. D. Rotate health care staff caring for the client.

Correct Answer is B

Explanation

A. Monitoring vital signs every 12 hours is a standard nursing intervention but may not specifically address the needs of a client with immunosuppression.
B. Inspecting the client's mouth every 8 hours can help in early detection of mouth sores or infections, which are common in immunosuppressed individuals.
C. Providing fresh fruit with meals may not be appropriate for a client with immunosuppression, as fresh fruits can harbor pathogens that pose a risk of infection.
D. Rotating healthcare staff caring for the client helps increases the risk of introducing pathogens to the client. This increases the risk of infection in the immunosuppressed client.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Body Systems	Findings
Head, Eyes, Ears, Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Hard stool
Hematologic	Increased bruising Increased bleeding tendency Insomnia
Genitourinary	Red/orange tint to urine Darkening of the urine

A nurse is caring for a client in a clinic. Exhibits Based on the information in the client's medical record, which of the following findings require immediate follow-up? Select the 4 findings that require follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is creating a plan of care for a client who has cancer and is experiencing Immunosuppression. Which of the following Interventions should the nurse include in the plan of care?

Correct Answer is B

Explanation

A nurse is providing teaching to a parent of a child who has varicella. Which of the following statements should the nurse include in the teaching?

A nurse is contributing to the plan of care for a client who has multiple sclerosis. The nurse should recommend including which of the following interventions in the plan of care to assist the client in overcoming barriers related to this condition?

A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse Identify as tertiary prevention?

A nurse is planning care for a client who is returning to the unit following open gastric bypass surgery. Which of the following interventions should the nurse include in the client's plan of care?

A nurse is assessing the fontanels of an 8-month-old infant. Which of the following findings should the nurse recognize as an expected finding?

A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?

A nurse is caring for a client who presents to the emergency department. Exhibits Select words from the choices below to fill in each blank in the following sentence. To further evaluate the client, the nurse anticipates the client will need dropdown and dropdown.

A nurse is caring for a client in a clinic.

Exhibits

Based on the information in the client's medical record, which of the following findings require immediate follow-up?

Select the 4 findings that require follow-up.