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.

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Correct Answer is C

Explanation

A. "The higher the score, the higher the pressure injury risk":

This statement is incorrect. The lower the score on the Braden scale, the higher the risk for pressure injuries. The total score is used to assess the overall risk, and a lower score indicates a higher risk.

B. "The client's age is part of the measurement":

This statement is incorrect. The client's age is not a factor in the Braden scale. The scale focuses on specific elements related to pressure injury risk, such as sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

C. "Each element has a range from one to five points":

This response indicates an understanding of the Braden scale. The scale measures six elements (sensory perception, moisture, activity, mobility, nutrition, and friction/shear), and each element is scored on a scale from 1 to 4 or 1 to 5 points, depending on the element. The total score ranges from 6 to 23, and a lower score indicates a higher risk for developing pressure injuries.

D. "The scale measures six elements":

While this statement is correct, it does not provide specific information about the scoring range for each element. The key aspect emphasized in the Braden scale is the scoring range for each element, as it helps determine the overall risk for pressure injuries.

A. Cholestrol level B. Prealbumin level C. History of malnutrition D. History of diabetes mellitus E. History of hyperlipidemia)

Correct Answer is ["B","C","D"]

Explanation

A. Cholesterol level:

While hyperlipidemia (elevated cholesterol levels) is associated with cardiovascular disease, it is not a direct factor affecting wound healing. Cholesterol levels primarily impact vascular health and are not directly related to the cellular and tissue processes involved in wound repair.

B. Prealbumin level:

Prealbumin is a protein that reflects recent dietary intake and nutritional status. Low prealbumin levels can indicate malnutrition, which is associated with delayed wound healing. Adequate protein intake is crucial for tissue repair and wound healing.

C. History of malnutrition:

Malnutrition is a significant risk factor for delayed wound healing. Adequate nutrition is essential for the body to carry out the processes involved in wound healing, including cell proliferation, collagen synthesis, and immune function.

D. History of diabetes mellitus:

Diabetes mellitus can impair wound healing due to factors such as reduced blood flow, impaired immune response, and neuropathy. Elevated blood sugar levels in diabetes can interfere with the normal healing processes, leading to delayed wound healing.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?

Correct Answer is C

Explanation

Client has a history of malnutrition, hyperlipidemia, and diabetes mellitus. The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.)

A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure. Which of the following actions should the nurse take first?

A nurse identifies a small fire in a client's room. After moving the client to safety, which of the following is the next action the nurse should take?

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

A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?

A nurse is preparing to administer medications to a client. At which of the following times should the nurse compare the medication administration record and the medication label? (Select all that apply.)

A nurse is collecting a blood pressure (BP) reading from a client who is sitting in a chair. The nurse determines that the client's BP is 158/96 mm Hg. Which of the following actions should the nurse take?

A nurse is planning care for a client who is immobile. Which of the following actions should the nurse include in the plan of care?