A nurse is caring for a client.

Vital Signs.

1600: Nurses' Notes.

Temperature 37.6°C (99.7°F). Blood pressure 110/58 mm Hg. Heart rate 72/min.

Respiratory rate 18/min.

Pulse oximetry 98% on room air.

1630: Temperature 37.5°C (99.5°F). Blood pressure 78/52 mm Hg. Heart rate 112/min.

Respiratory rate 26/min.

Pulse oximetry 92% on room air.

1600: Antibiotic administered as prescribed.

Bilateral breath sounds clear and present throughout.

1630: Client reports itching on the chest and has urticaria over the chest and trunk.

Client states they are having difficulty swallowing and feel as if there is a lump in their throat.

Bilateral breath sounds with scattered wheezing heard throughout.

Vital Signs.

Nurses' Notes.

Medication Administration Record.

Cefaclor 500 mg PO q8h.

Select the 3 findings that require immediate follow-up.

Breath sounds at 1600.

Temperature.

Urticaria.

Blood pressure at 1630.

Report of dysphagia.

Answer and Explanation

Correct Answer : C,D,E

The correct answer is to select the following three findings that require immediate follow-up: C. Urticaria, D. Blood pressure at 1630, and E. Report of dysphagia.

Choice A rationale:

“Breath sounds at 1600.” The breath sounds at 1600 were clear and present throughout, which is a normal finding and does not require immediate follow-up.

Choice B rationale:

“Temperature.” The temperature readings at both 1600 and 1630 are slightly elevated but not critically high. This does not require immediate follow-up compared to the other findings.

Choice C rationale:

“Urticaria.” The presence of urticaria (hives) indicates an allergic reaction, which can potentially escalate to a more severe reaction such as anaphylaxis. Immediate follow-up is necessary to prevent further complications.

Choice D rationale:

“Blood pressure at 1630.” The blood pressure at 1630 is significantly lower (78/52 mm Hg) compared to the earlier reading (110/58 mm Hg). This hypotension could indicate a serious reaction to the medication or another underlying issue that requires prompt attention.

Choice E rationale:

“Report of dysphagia.” The client’s report of difficulty swallowing and feeling a lump in their throat is concerning for a potential airway obstruction or severe allergic reaction, such as anaphylaxis. This symptom requires immediate follow-up to ensure the client’s airway remains open and to provide necessary interventions.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

The correct answer is Choice B: Nursing Scope and Standards of Practice.

Choice A rationale:

The Code of Ethics for Nurses provides guidelines on ethical practice but does not specifically address pay.

Choice B rationale:

The Nursing Scope and Standards of Practice outlines the professional standards, including aspects related to compensation and benefits, which can help guide a nurse in understanding pay scales and expectations.

Choice C rationale:

American Nurses Association Position Statements provide guidance on various issues but are not focused on pay.

Choice D rationale:

Principles of Nursing Practice offer a framework for nursing care but do not specifically address salary or compensation.

A. Phlebitis. B. Infection. C. Infiltration. D. Circulatory overload.

Correct Answer is C

Explanation

Choice A rationale:

Phlebitis is inflammation of a vein, often associated with pain, redness, and warmth at the catheter site. In this case, the client's catheter site is described as cool and taut, which is not consistent with the manifestations of phlebitis.

Choice B rationale:

Infection typically presents with signs such as redness, warmth, swelling, and pain at the catheter site. The description of the client's catheter site as cool and taut is not indicative of infection.

Choice C rationale:

The client's symptoms, including a cool and taut catheter site and IV fluid leaking, are indicative of infiltration. Infiltration occurs when IV fluids inadvertently enter the surrounding tissue instead of the vein. It can lead to localized swelling and discomfort.

Choice D rationale:

Circulatory overload is characterized by symptoms such as shortness of breath, elevated blood pressure, and tachycardia. These symptoms are not consistent with the client's description of a cool and taut catheter site with IV fluid leaking.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A newly licensed nurse is applying for their first job and wants guidance on pay. Which of the following professional standards should the nurse review?

Correct Answer is B

Explanation

A nurse is assessing a client who is receiving continuous IV therapy through a peripheral IV. The catheter site is cool and taut, and there is IV fluid leaking.The nurse should identify that the client has manifestations of which of the following complications?

Correct Answer is C

Explanation

A public health nurse is preparing an educational session at a community health center about the social determinants of health (SDOH). Which of the following information should the nurse include?

A nurse is caring for a client who is at the end of life.Which of the following interventions is most effective in reducing the client's social isolation?

A nurse is preparing an in-service about communication for a group of staff nurses.Which of the following information should the nurse include when discussing the electronic mode of communication?

A nurse is teaching a class about the transition from novice to expert nurse. The nurse should include that a nurse who is a preceptor to new staff members is at which of the following stages?

A nurse is providing an in-service to a group of newly licensed nurses on standards of practice and the role of the Board of Nursing (BON). Which of the following information should the nurse include?

A charge nurse is providing an in-service to a group of nurses on the different levels of illness prevention. The nurse should include which of the following as an example of secondary prevention?

A nurse is collecting research to revise the protocol for specimen collection on their unit.From which of the following sources should the nurse retrieve the information?

A nurse is preparing an in-service to review the Code of Ethics (COE) with a group of nursing colleagues.Which of the following statements should the nurse make during the in-service about the COE?