A nurse is caring for a client.

Nurses' Notes

Heart rate

0800:

Antibiotics administered as prescribed.

Bilateral breath sounds clear and present throughout.

0830:

The client reports itching over the chest area and has urticaria over the chest and trunk.

The client states tongue feels swollen.

Bilateral breath sounds with scattered wheezing upon auscultation.

Select the 4 findings that require immediate follow-up.

Swollen tongue

Heart rate

Breath sounds

Blood pressure

Temperature

Urticaria

Answer and Explanation

Correct Answer : A,B,C,F

A.Swollen tongue: Swelling of the tongue can indicate an allergic reaction, which could progress to a severe condition known as anaphylaxis. Immediate intervention is necessary.

B. Heart rate: While the heart rate is not directly mentioned in the notes, an increase in heart rate could be a physiological response to an allergic reaction or anaphylaxis. Monitoring heart rate is crucial in assessing the severity of the reaction.

C. Bilateral breath sounds with scattered wheezing upon auscultation: Wheezing indicates a potential respiratory issue, and when associated with itching, urticaria, and swelling, it suggests an allergic reaction or anaphylaxis. Prompt intervention is needed.

D. Blood pressure: Although blood pressure is important to monitor, it is not directly mentioned in the nurses' notes. However, if anaphylaxis or a severe allergic reaction is suspected, blood pressure can be affected, and it should be monitored.

E. Temperature: Fever is not mentioned in the notes, and the information provided suggests an immediate allergic reaction rather than an infectious process. Monitoring temperature is generally important but may not be a priority in this specific context.

F.Urticaria (hives): Hives are a sign of an allergic reaction and, when accompanied by other symptoms like swelling, require immediate attention.

Nursing Test Bank

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Correct Answer is C

Explanation

A. An assistive personnel prevents a client from leaving the facility:

This situation may raise ethical concerns related to patient autonomy and freedom of movement. However, it is not a clear example of negligence. Negligence is more directly related to the provision of care and the failure to meet the standard of care.

B. An assistive personnel discusses client care in the facility cafeteria with visitors present:

This situation involves a breach of confidentiality and may violate the Health Insurance Portability and Accountability Act (HIPAA). However, it is not an example of negligence. Negligence typically involves a failure to provide appropriate care rather than a breach of privacy.

C. A nurse administers a medication without first identifying the client:

This is an example of negligence. Negligence refers to the failure to provide the standard of care that a reasonably prudent person would have provided under similar circumstances. In this case, administering medication without first identifying the client is a breach of the standard of care, and it can lead to serious consequences, including harm to the patient.

D. A nurse begins a blood transfusion without obtaining consent from a client:

This is an example of a legal issue related to lack of informed consent. While it raises ethical and legal concerns, it may not necessarily be considered negligence, which is more related to a failure in providing care up to the standard. However, it is still a serious violation of ethical and legal principles.

A. Metabolic syndrome B. Family history of alcohol use disorder C. Hypotension D. Participation in competitive sports

Correct Answer is A

Explanation

A. Metabolic syndrome:

Metabolic syndrome is a cluster of conditions that increase the risk of cardiovascular disease, diabetes, and stroke. These conditions include elevated blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels. Individuals with metabolic syndrome are at an increased risk of developing cardiovascular disease.

B. Family history of alcohol use disorder:

While a family history of alcohol use disorder may contribute to various health issues, it is not a direct risk factor for cardiovascular disease. However, excessive alcohol consumption itself can contribute to cardiovascular problems.

C. Hypotension:

Hypotension, or low blood pressure, is generally not considered a risk factor for cardiovascular disease. In fact, low blood pressure is often associated with a reduced risk of certain cardiovascular events.

D. Participation in competitive sports:

Participation in competitive sports, in general, is not a risk factor for cardiovascular disease. In fact, regular physical activity is often recommended for cardiovascular health. However, the specific type and intensity of sports activities, as w

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collaborating with a risk management team about potential legal issues involving client care. The nurse should identify that which of the following situations is an example of negligence?

Correct Answer is C

Explanation

A nurse is obtaining a health history from a client. Which of the following factors places the client at risk for cardiovascular disease?

Correct Answer is A

Explanation

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