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A nurse is reviewing the medical record of a client.

Exhibits

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

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:

A. Moving the stronger leg forward before moving the weaker leg is incorrect and may increase the risk of falls.

B. Holding the cane on the stronger side provides support and stability while walking.

C. Moving the cane forward 18 inches is incorrect and may increase the risk of falls.

D. Wearing shoes with smooth soles may decrease traction and increase the risk of falls.

A. "I will clean around the stoma with a moisturizing soap." B. "I will press on the skin barrier for 30 seconds to ensure that it adheres." C. "I will cut an opening in the skin barrier that is 1/2 inch larger than the stoma." D. "I will apply a thin layer of talc powder around the stoma before placing the appliance."

Correct Answer is B

Explanation

A. Cleaning around the stoma with a moisturizing soap is not recommended. Moisturizing soaps can leave a residue that may interfere with the adhesion of the skin barrier. The client should use warm water or a mild, non-moisturizing soap to clean the area.

B. Pressing on the skin barrier for 30 seconds to ensure that it adheres is correct. This technique helps secure the barrier to the skin, creating a good seal and reducing the risk of leaks.

C. Cutting an opening in the skin barrier that is 1/2 inch larger than the stoma is incorrect. The opening should be about 1/8 inch larger than the stoma to ensure a snug fit, which helps protect the surrounding skin from exposure to effluent.

D. Applying a thin layer of talc powder around the stoma before placing the appliance is not appropriate. Powders are typically used to manage irritated skin but should be avoided unless specifically recommended by a healthcare provider. Overuse can interfere with the appliance’s adhesion.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about the use of a quad cane. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who has an ostomy. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is assisting with feeding a client who has had a stroke. Which of the following findings should the nurse identify as a manifestation of dysphagia?

A nurse at a long-term care facility is caring for an older adult client who has dementia and is at risk for malnutrition. Which of the following actions should the nurse take to promote an increase in food intake?

A nurse is caring for a client who is postpartum. Which of the following documentations should the nurse include in the client's health record?

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A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply)

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