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

Exhibits

Select the 4 assessment findings on day 2 that require immediate follow-up.

Heart rate

Oxygen saturation

Edema

Temperature

Urine color

Pedal pulses

Answer and Explanation

Correct Answer : A,C,E,F

A. Heart rate: The increased heart rate (108/min) may indicate a developing complication such as hypovolemia or pain. This requires monitoring as it could signal deteriorating status.

B. Oxygen saturation: The SpO₂ level is stable at 96%, which is within an acceptable range and does not indicate an immediate concern.

C. Edema: The increase in sacral and iliac region edema (2+) from day 1 to day 2 suggests worsening swelling and possible fluid accumulation, which could be affecting blood flow and leading to circulatory issues.

D. Temperature: The temperature remains within a normal range, so it does not require immediate intervention.

E. Urine color: Dark, reddish-brown urine suggests possible bleeding or rhabdomyolysis, both of which require immediate follow-up to prevent further complications and assess kidney function.

F. Pedal pulses: The change to 1+ pedal pulses bilaterally and the delayed capillary refill time (6 seconds) indicate reduced perfusion to the lower extremities, which may suggest compromised circulation or increased edema affecting blood flow.

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Correct Answer is A

Explanation

A. Moving objects away prevents injury during the seizure and is a critical safety measure.

B. Placing the client on their side, rather than on their back, helps maintain an open airway and prevents aspiration.

C. Inserting anything into the client's mouth, including a padded tongue blade, is not recommended as it may cause injury.

D. Restraining the client could result in injury and is not advised.

A. Comminuted B. Transverse C. Impacted D. Oblique

Correct Answer is A

Explanation

A. A comminuted fracture is characterized by the bone being splintered or crushed into multiple fragments, as seen in this client’s x-ray.

B. A transverse fracture is a straight horizontal break across the bone.

C. An impacted fracture occurs when bone fragments are driven into each other.

D. An oblique fracture has a diagonal break across the bone but does not involve multiple splinters.

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A nurse is caring for a client in the emergency department (ED). Exhibits Select the 4 assessment findings on day 2 that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Á nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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

Exhibits

Select the 4 assessment findings on day 2 that require immediate follow-up.