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A nurse is caring for a client in an outpatient clinic.

Exhibits

Click to highlight the findings that require further evaluation, to deselect a finding, click on the finding again.

Body System

Findings

Neurological

Reports that dizziness and palpitations started 2 months ago.

Alert and oriented to person, place, and time

Cardiovascular

Pedal pulses +1 bilaterally, Pedal edema +1 bilaterally. Capillary refill time 5 seconds for all extremities. Reports no pain with palpation of thorax.

Respiratory

Fatigue and dyspnea with exertion started 1 week ago.

Lungs clear to auscultation bilaterally

Vital Signs

Heart rate 105/min

Respiratory rate 20/min

Blood pressure 164/92 mm Hg

Oxygen saturation 96% on room air

Reports that dizziness and palpitations started 2 months ago.

Alert and oriented to person, place, and time

Pedal pulses +1 bilaterally, Pedal edema +1 bilaterally.

Capillary refill time 5 seconds for all extremities.

Fatigue and dyspnea with exertion started 1 week ago.

Lungs clear to auscultation bilaterally

Heart rate 105/min

Blood pressure 164/92 mm Hg

Answer and Explanation

The Correct Answer is ["A","C","D","E","G"]

Rationale for correct choices

• Neurological: Reports that dizziness and palpitations started 2 months ago: Persistent dizziness and palpitations may indicate arrhythmias, decreased cardiac output, or early cardiovascular compromise. Although the client is alert and oriented, these symptoms suggest insufficient cerebral perfusion or possible underlying cardiac pathology that requires further evaluation.

• Cardiovascular: Pedal pulses +1 bilaterally, Pedal edema +1 bilaterally, Capillary refill time 5 seconds for all extremities: Diminished pulses, mild edema, and prolonged capillary refill time indicate potential peripheral arterial insufficiency and early signs of fluid overload or heart failure. These findings suggest impaired circulation and warrant further assessment.

• Respiratory: Fatigue and dyspnea with exertion started 1 week ago: New-onset exertional dyspnea and fatigue may be early indicators of compromised cardiac or pulmonary function. Despite clear lung sounds, these symptoms suggest reduced oxygen delivery or early heart failure. Prompt evaluation is required to prevent progression and to identify reversible causes.

• Vital Signs: Heart rate 105/min, Blood pressure 164/92 mm Hg: Tachycardia and hypertension indicate increased cardiac workload and potential risk for end-organ damage. Persistent elevated BP above 140/90 mm Hg is associated with cardiovascular complications, including left ventricular hypertrophy and renal impairment. Monitoring and further evaluation of cardiac function, lifestyle factors, and medication adherence are necessary.

Rationale for incorrect choices

• Neurological: Alert and oriented to person, place, and time: Being alert and oriented reflects intact cognitive function and does not require immediate further evaluation. While neurological changes may arise secondary to cardiac issues, orientation alone is within normal limits and is not concerning. This finding does not indicate acute pathology.

• Respiratory: Lungs clear to auscultation bilaterally: Clear lung sounds suggest no active pulmonary congestion, infection, or obstruction. Although dyspnea is present, the absence of adventitious lung sounds indicates that the respiratory system is not acutely compromised. Further evaluation focuses on cardiac or systemic causes rather than pulmonary pathology.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:

A. Inform the transferring agency of the client's condition: While notifying the transferring facility may be part of documentation or reporting, it does not directly address suspicions of abuse. The priority is to gather accurate information from the client in a safe and confidential manner before reporting.

B. Notify risk management: Risk management may be involved in internal investigation processes, but contacting them is not the first step when abuse is suspected. Immediate priority is assessing the client’s safety and obtaining information about the injuries.

C. Privately interview the client about the injuries: Conducting a private, nonjudgmental interview allows the nurse to gather direct information about the cause of the injuries without influence or intimidation from others. This is a critical first step in identifying potential elder abuse, ensuring the client’s safety, and providing evidence for appropriate reporting.

D. Contact the family regarding the client's condition: Contacting family members before assessing the client can compromise the investigation, particularly if family members are potential perpetrators. Privacy and safety of the client must be prioritized before involving others.

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}

Explanation

Rationale for Correct Choices

Intravenous antibiotics: The client presents with uterine tenderness, dark foul-smelling lochia, a mildly elevated temperature, and an elevated WBC count, all of which point to endometritis, a common postpartum infection. The first-line treatment for endometritis is broad-spectrum IV antibiotics to prevent complications like sepsis.
Increase in daily fluid intake: Infection and fever can increase fluid loss through insensible means, and fluids support circulation, renal function, and antibiotic delivery. Encouraging increased fluid intake also helps address dehydration from fever and supports healing and lactation.

Rationale for Incorrect Choices

Kleihauer-Betke test: This test detects fetal-to-maternal hemorrhage and is used in trauma or suspected placental abruption in Rh-negative mothers. There is no indication of bleeding or Rh incompatibility in this case, so it is not appropriate here.
Tocolytic medication: Tocolytics are used to suppress uterine contractions in preterm labor. This client is postpartum and has no signs of preterm labor or uterine hyperstimulation, so this medication is not warranted.
Intrauterine tamponade balloon: This device is used for severe postpartum hemorrhage due to uterine atony that doesn’t respond to medical treatment. The client has moderate lochia but no signs of active hemorrhage or hemodynamic instability, so it is not indicated.

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Body System	Findings
Neurological	Reports that dizziness and palpitations started 2 months ago. Alert and oriented to person, place, and time
Cardiovascular	Pedal pulses +1 bilaterally, Pedal edema +1 bilaterally. Capillary refill time 5 seconds for all extremities. Reports no pain with palpation of thorax.
Respiratory	Fatigue and dyspnea with exertion started 1 week ago. Lungs clear to auscultation bilaterally
Vital Signs	Heart rate 105/min Respiratory rate 20/min Blood pressure 164/92 mm Hg Oxygen saturation 96% on room air

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client's coccyx and abrasions around both wrists. Which of the following actions should the nurse take to address suspicions of elder abuse?

Correct Answer is C

Explanation

A nurse on a postpartum unit is caring for a client. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The nurse should anticipate provider's prescription for a(n)dropdown and dropdown.

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}

Explanation

A nurse is planning to administer 2 units of packed RBCs to an older adult client who has anemia. Which of the following actions should the nurse plan to take? (Select all that apply.)

A nurse is providing dietary teaching to the guardian of a preschooler who has a new diagnosis of celiac disease. Which of the following statements by the guardian indicates an understanding of the teaching?

A nurse in a community clinic is caring for a client who has erythema migrans. The nurse should implement which of the following precautions?

A nurse is planning care for a client who is scheduled to receive a peripherally inserted central catheter in the arm. Which of the following interventions is appropriate for the nurse to include in the plan of care?

A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for cyanosis?

A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following findings as an indication that the medication has been effective?

A nurse is caring for a client who is receiving oxytocin and notes that the electronic fetal monitor shows persistent late decelerations. Which of the following actions should the nurse take?

A nurse is caring for a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect?