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 |
deep tendon reflexes 4+
Heart rate irregular
Bowel sounds hyperactive x 4 quadrants
Generalized weakness with equal bilateral muscle strength and mild leg cramping
Lungs clear
Heart rate 95/min
Alert and oriented to person, place, and time;
The Correct Answer is ["A","B","C","D"]
An irregular heart rhythm could indicate potential cardiovascular issues. Additionally, deep tendon reflexes graded at 4+ suggest hyperreflexia, which may be associated with neurological disorders and should be investigated further.
Hyperactive bowel sounds in all four quadrants could indicate gastrointestinal hypermotility, which might require prompt assessment to determine the underlying cause.
Generalized weakness and mild leg cramping also require follow-up to determine the cause.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is E,B,C,D,A
Explanation
First, the nurse should apply clean gloves (E) to maintain sterility and safety. Next, the nurse should disconnect the tube from the suction device (B), ensuring that the device is no longer actively working on the tube.
Before removing the tube, it is important to instill air into it (C); this helps clear any residual contents and minimizes the risk of aspiration. The nurse should then ask the client to take a deep breath (D), which helps close the epiglottis to prevent aspiration during the removal of the tube. Finally, the nurse can pinch and withdraw the tube (A), completing the process in a swift, steady motion to ensure comfort and safety for the client.
Correct Answer is C
Explanation
A) Add 0.5 mL of diluent to the medication. - This action is not appropriate for administering medication from an ampule since the diluent may alter the concentration and dosage of the medication.
B) Inject air into the ampule prior to drawing the medication into a syringe. - Injecting air into the ampule is unnecessary and may cause contamination.
C) Use a filter needle to aspirate the medication. - Filter needles can prevent glass particles from being drawn into the syringe when aspirating medication from an ampule.
D) Cleanse the tip of the ampule with an alcohol swab after opening. – This action is unnecessary and may contaminate the medication.
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