A nurse is reviewing the medical record of a client.
Click to highlight below the findings that require immediate follow-up.
Body system/Findings
Neurological- Alert and oriented to person, place, and time; deep tendon reflexes 4+
Musculoskeletal - Generalized weakness with equal bilateral muscle strength and mild leg cramping
Respiratory- Lungs clear
Cardiovascular- Heart rate irregular: Heart rate 95/min
Gastrointestinal- Bowel sounds hyperactive x 4 quadrants
Neurological- Alert and oriented to person, place, and time; deep tendon reflexes 4+
Musculoskeletal - Generalized weakness with equal bilateral muscle strength and mild leg cramping
Respiratory- Lungs clear
Cardiovascular- Heart rate irregular: Heart rate 95/min
Gastrointestinal- Bowel sounds hyperactive x 4 quadrants
The Correct Answer is ["D","E"]
Rationale:
A. These neurological findings are within normal limits and do not require immediate follow-up.
B. These musculoskeletal findings are not indicative of an emergency and can be addressed during routine care.
C. Clear lung sounds are a normal finding and do not require immediate follow-up.
D. An irregular heart rate may indicate an arrhythmia or other cardiovascular issue that requires further assessment and intervention.
E. Hyperactive bowel sounds can indicate a variety of gastrointestinal issues, including bowel obstruction or ileus, which may require immediate intervention or further investigation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Applying lidocaine gel to the urethra may provide additional lubrication but does not address the immediate issue of resistance during catheter insertion.
B. Inflating the catheter's balloon is inappropriate at this stage, as the catheter is not properly positioned for urine flow, and doing so could cause injury.
C. Lowering the penis to a 45° angle helps to straighten the urethra and can facilitate easier passage of the catheter, making it the most appropriate action.
D. Twisting the catheter gently is not recommended, as this may cause trauma to the urethra or increase discomfort without resolving the resistance issue.
Correct Answer is ["B","D"]
Explanation
A. The client is already on a daily dose of Metoprolol, and there is no indication that the dose should be increased. In fact, it is important to monitor the client's blood pressure and heart rate closely due to the potential side effects of Metoprolol.
B. This is the appropriate action since the client is allergic to penicillin, and the prescription for amoxicillin should be reviewed with the provider.
C. There is no indication from the information provided that the client requires a surgical mask when outside their room.
D. The client has been vomiting and experiencing abdominal cramping, which suggests nausea and discomfort. Requesting a prescription for an antiemetic medication is an appropriate action to address these symptoms.
E. There is no indication from the information provided that the client requires contact precautions. The client has a urinary tract infection and is not exhibiting symptoms consistent with a condition that requires contact precautions.
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