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 {"dropdown-group-1":"D","dropdown-group-2":"D"}

Explanation

Cardiovascular abnormalities are a serious risk in clients with bulimia nervosa due to electrolyte imbalances, especially hypokalemia, which can lead to arrhythmias, weakened heart muscles, and potential heart failure. Hyponatremia (low sodium levels) can occur due to excessive vomiting, which leads to the loss of fluids and electrolytes, including sodium. Incorrect responses: Group 1: Hypoglycemia: Bulimia nervosa primarily causes electrolyte imbalances and acid-base disturbances due to vomiting, not significant alterations in blood sugar levels. Metabolic Acidosis: Vomiting leads to the loss of gastric acid, causing metabolic alkalosis. Hypotension: Hypotension could occur if the client experiences significant dehydration from vomiting. Hypotension would be a consequence of severe dehydration rather than a primary risk at this stage. Hyperglycemia: Hyperglycemia is not typically associated with bulimia nervosa or vomiting. It would be more relevant in conditions like diabetes. Group 2: Hyperkalemia: Hyperkalemia (high potassium) is unlikely in bulimia nervosa, where frequent vomiting usually leads to hypokalemia due to the loss of potassium in gastric secretions. Metabolic Acidosis: As mentioned before, vomiting leads to metabolic alkalosis, not acidosis, because of the loss of hydrochloric acid. Hypochloremia: Hypochloremia (low chloride levels) can occur with vomiting due to the loss of stomach acid, which contains chloride. While it is a possible outcome, metabolic alkalosis better captures the overall acid-base disturbance in the client.

A. Select a 1-inch needle. B. Use a 45° angle when inserting the needle. C. Use the ventrogluteal site. D. Pinch the skin up during injection.

Correct Answer is C

Explanation

A. Incorrect. A 1-inch needle may not be long enough to reach the muscle layer in an obese client, which may result in subcutaneous injection and reduced absorption of the medication.

B. Incorrect. A 45° angle may not be appropriate for an IM injection, as it may cause the needle to enter at an oblique angle and miss the muscle layer or hit a bone or nerve.

C. Correct. The ventrogluteal site is preferred for IM injections in obese clients, as it has less subcutaneous fat and a large muscle mass that can accommodate larger volumes of medication.

D. Incorrect. Pinching the skin up during injection may cause the needle to enter at a shallow angle and deposit the medication in the subcutaneous tissue instead of the muscle layer.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has bulimia nervosa. Exhibits The client is at risk for developing dropdown and dropdown

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"D"}

Explanation

A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse is providing dietary teaching to a client who has a new prescription for phenelzine. Which of the following food recommendations should the nurse make? (Select all that apply.)

A nurse is performing a skin assessment on a client who has a dark skin. Which one of the following locations on the client’s body should the nurse observe to access for jaundice?

A nurse is admitting a client who has pneumonia. The nurse should initiate which of the following isolation precautions for the client?

A nurse is suctioning the airway of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following findings should the nurse identify as an indication that the suctioning has been effective?

A nurse is providing education to the parent of a school-age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching?

In caring for a client who requires seizure precautions, the practical nurse (PN) should ensure the ready availability of equipment to perform which procedure?

A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client?

A nurse is caring for a 2-month-old infant who has Hirschsprung disease (HD). Which of the following areas should the nurse assess for manifestations of HD? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)