A nurse is caring for a client in the emergency department.

Click to highlight the findings that indicate that the client's condition is improving. To deselect a finding, click on the finding again.

Nurses notes:

1400:

Client admitted to the medical-surgical unit at 1200 today. Alert and orientated x4, heart and lung sounds clear. Client urinating 100 mL/hour. Client is tolerating soft diet and oral fluids. Bowel sounds are hyperactive in all 4 quadrants. Bilateral pedal pulses 2+. Blood glucose 310 mg/dL (74 to 106 mg/dL)

Vital signs:

1400:

Temperature 36.8° C (98.2 F)

Pulse rate 84/min

Respiratory rate 16/min

Blood pressure 106/76 mm Hg

Oxygen saturation 96% on room air

Alert and orientated x4, heart and lung sounds clear

Client is tolerating soft diet and oral fluids

Temperature 36.8° C (98.2 F)

Answer and Explanation

The Correct Answer is ["A","B"]

Rationale

Client is alert and oriented x4, heart and lung sounds clear.
This shows that the client is stable and no longer experiencing confusion or respiratory distress, which are signs of improvement.

Client is tolerating soft diet and oral fluids.
The ability to tolerate food and fluids is a sign of recovery and better overall condition

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["69"]

Explanation

 Convert pounds to kilograms: There are approximately 2.2 pounds in 1 kilogram.

190 lb / 2.2 lb/kg = 86.36 kg (approximately)

 Calculate protein needs based on RDA: The RDA is 0.8 g/kg.

86.36 kg x 0.8 g/kg = 69.09 g

 Round to the nearest whole number:

69 g

A. Loss of hearing B. Muscle wasting C. Changes in vision D. Paresthesia

Correct Answer is D

Explanation

A. Loss of hearing is not a common or expected manifestation of pernicious anemia. It is typically associated with other conditions, such as age-related hearing loss or certain types of neurological disorders.

B. Muscle wasting is not a typical manifestation of pernicious anemia. While muscle weakness may occur, it is not generally characterized by muscle wasting.

C. Changes in vision are not a common manifestation of pernicious anemia. However, some neurological symptoms may affect vision, but these are typically secondary to more severe or untreated cases.

D. Paresthesia (numbness or tingling, especially in the hands and feet) is a common manifestation of pernicious anemia due to vitamin B12 deficiency, which can lead to neurological impairment. This poses a safety risk as it can affect the client’s ability to feel and respond to environmental stimuli, increasing the risk of falls or injury.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["69"]

Explanation

A home health nurse is assessing a client who has pernicious anemia. Which of the following is an expected manifestation that poses a risk to the client's safety?

Correct Answer is D

Explanation

A nurse is assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain?

A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Exhibits For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

A nurse is assessing a client who is postoperative following an open reduction and internal fixation (ORIF) of the femur. Which of the following assessments should be the nurse's priority?

A nurse is caring for a client who is postoperative following an endoscopy with moderate (conscious) sedation. Which of the following assessment findings is the nurse's priority?

A nurse is caring for a client who is receiving chemotherapy and requests information about acupuncture to relieve some of the side effects. Which of the following findings should the nurse identify as a contraindication to receiving this alternative therapy?

A nurse is providing instructions to a client who has primary syphilis. Which of the following instructions should the nurse include in the discharge plan?

A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Exhibits The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up.