A nurse is caring for an adolescent.
Admission Assessment
1400:

Adolescent brought to emergency department by parents following a fall while skateboarding.

Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight.

Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm.

Abdomen soft and nontender with active bowel sounds in all four quadrants.

Right lower extremity with open wound and displaced bone.

Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds.

Select the 4 findings that require follow-up.

Blood pressure

Capillary refill

Pedal pulse

Heart rate

Skin temperature

Pain

Answer and Explanation

Correct Answer : B,C,E,F

A. Blood pressure: A normal blood pressure for an adolescent is 110/70 mm Hg. The question does not provide the adolescent's blood pressure, so it cannot be determined if it requires follow-up or not.
B. Capillary refill: A normal capillary refill time is less than 2 seconds. A prolonged capillary refill time indicates impaired blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
C. Pedal pulse: A normal pedal pulse is +2 or +3. A weak pedal pulse (+1) indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.

D. Heart rate: A normal heart rate for an adolescent is 60 to 100 beats per minute. The question does not provide the adolescent's heart rate, so it cannot be determined if it requires follow-up or not.
E. Skin temperature: A normal skin temperature is warm and dry. A cool skin temperature indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
F. Pain: A pain level of 10 on a scale of 0 to 10 indicates severe pain that needs to be managed with appropriate analgesics and nonpharmacological interventions.

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Correct Answer is D

Explanation

Option A is incorrect because enrolling the UAP in a hospital education class on conducting safe client care does not address the immediate problem or correct the error.

Option B-This would be inappropriate for oral care in an unconscious client as it increases the risk of aspiration.The side-lying position is safer for oral hygiene in unconscious clients.

Option C:While encouraging family participation can be beneficial, it is not the most immediate concern in this situation. The priority is ensuring safe and effective care, which the UAP is providing correctly.

Option D:The flat side-lying position is appropriate for an unconscious client during oral hygiene care. This position helps to prevent aspiration by allowing any secretions or fluids to drain out of the mouth rather than down the throat, which could happen if the client were in a Fowler's position. The presence of the emesis basin near the chin also indicates that the UAP is prepared to catch any fluids, further reducing the risk of aspiration

A. "I will avoid using my microwave oven at home because of the ICD." B. "I can hold my cell phone on the same side of my body as the ICD." C. "I will wear loose clothing over my ICD D. "I will soak in the tub rather than showering."

Correct Answer is C

Explanation

Choice A reason:

"I will avoid using my microwave oven at home because of the ICD."This statement is incorrect. Using a microwave oven does not interfere with the functioning of an ICD. It is safe for clients with ICDs to use microwave ovens.

Choice B reason:

"I can hold my cell phone on the same side of my body as the ICD."This statement is incorrect Holding a cell phone on the same side of the body as the ICD should not cause any harm or interfere with the device's functioning.

Choice C reason:

"I will wear loose clothing over my ICD." This statement is correct and demonstrates understanding of the teaching. Wearing loose clothing over the ICD helps prevent excessive pressure or friction on the device and reduces the risk of dislodging the ICD leads or causing discomfort.

Choice D reason:

"I will soak in the tub rather than showering." This statement is incorrect. Avoiding showers is not necessary for clients with ICDs. Taking showers is generally safe for individuals with ICDs, as the device is designed to be waterproof and withstand such conditions.

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Naxlex Comprehensive Predictor Exams

The practical nurse (PN) observes an unlicensed assistive personnel (UAP) performing oral hygiene on an unconscious client who is lying in a ﬂat side-lying position with an emesis basin on the bedside table near the chin. Which action should the PN take?

Correct Answer is D

Explanation

A nurse is providing discharge teaching for a client who has a new implantable cardioverter defibrillator (ICD). Which of the following client statements demonstrates understanding of the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving positive end-expiratory pressure (PEEP) via mechanical ventilation. The nurse should monitor the client for which of the following adverse effects of PEEP?

A nurse manager in a long-term care facility is having difficulty with staffing for weekend shifts and is planning to implement some changes to the scheduling procedure. Which of the following actions should the nurse manager take first?

A nurse is evaluating the laboratory values of a client who is receiving epoetin alfa. Which of the following findings indicates a therapeutic response to the medication?

A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse's priority?

A nurse is caring for a client receiving mechanical ventilation via an endotracheal (ET) tube. The high-pressure alarm is beeping, and the client is experiencing respiratory distress. The nurse is unable to determine the cause of the alarm. Which of the following actions should the nurse take?

During a change-of-shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. Which of the following actions should the day shift nurse take?

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