Click to highlight the findings that require immediate follow-up. (Select all that apply)

Respiratory rate 11/min

SpO2 > 94% on room air

Lungs clear to auscultation

Reports pain worsening in right forearm.

States right hand is “tingly.”

Able to move fingers

Answer and Explanation

The Correct Answer is ["D","E"]

Choice A reason: A respiratory rate of 11/min is slightly below normal (12-20/min) but not immediately concerning in a stable elderly client without respiratory distress. It warrants monitoring but does not require urgent follow-up compared to neurological or musculoskeletal symptoms.

Choice B reason: SpO2 > 94% on room air is normal, indicating adequate oxygenation. This finding does not suggest respiratory compromise, so it does not require immediate follow-up, aligning with expected respiratory status in a stable client.

Choice C reason: Clear lung auscultation is a normal finding, indicating no airway obstruction or fluid. It does not suggest respiratory pathology, so it does not require immediate follow-up, reflecting stable pulmonary function in the client’s assessment.

Choice D reason: Worsening forearm pain after a fall suggests potential fracture, compartment syndrome, or nerve injury, especially in an elderly client. This escalating symptom requires immediate imaging and evaluation to prevent complications like tissue damage, making it critical for follow-up.

Choice E reason: Tingling in the right hand indicates possible nerve compression or injury, such as radial nerve damage from a fall. This neurological symptom demands urgent assessment to prevent permanent impairment, making it a priority for immediate follow-up.

Choice F reason: Ability to move fingers is a positive finding, suggesting some preserved motor function. While reassuring, it does not negate the need to address worsening pain and tingling, so it does not require immediate follow-up compared to other symptoms.

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Correct Answer is C

Explanation

Choice A reason: Dizziness is unrelated to paralytic ileus, which involves impaired bowel motility post-surgery, causing distention. Dizziness may indicate hypovolemia or anesthesia effects. Assuming dizziness indicates ileus risks misdiagnosis, delaying interventions like nasogastric suction for ileus, potentially worsening bowel obstruction and client discomfort in postoperative care.

Choice B reason: Watery stool suggests diarrhea, not paralytic ileus, which causes absent bowel sounds and constipation due to motility loss. Misidentifying watery stool as ileus risks overlooking infectious causes, delaying appropriate treatments like antidiarrheals, while neglecting ileus interventions, critical for restoring bowel function post-orthopedic surgery.

Choice C reason: Abdominal distention is a hallmark of paralytic ileus, resulting from postoperative bowel motility cessation, leading to gas and fluid accumulation. Recognizing this guides interventions like bowel rest or decompression, critical for preventing complications like perforation, ensuring timely recovery, and reducing discomfort in clients post-orthopedic surgery.

Choice D reason: Oliguria (low urine output) indicates renal issues, not paralytic ileus, which presents with distention and absent bowel sounds. Assuming oliguria is ileus-related risks missing dehydration or kidney injury, delaying fluid management, while neglecting ileus treatments, critical for addressing postoperative bowel dysfunction and client recovery.

A. Discuss a long-term care referral for the client with the provider. B. Suggest that the client attend adult day care three times per week. C. Review assisted living accommodations with the client. D. Instruct the client about the use of telehealth services.

Correct Answer is D

Explanation

Choice A reason: A long-term care referral is premature for an independent client with type 2 diabetes, as it assumes significant functional decline. Rural clients benefit from accessible care like telehealth to manage chronic conditions, making this intervention less appropriate than supporting independence.

Choice B reason: Adult day care three times weekly is unnecessary for an independent client and may not address diabetes management directly. It is less practical in rural areas with limited access, making telehealth a more feasible and targeted intervention for ongoing care.

Choice C reason: Reviewing assisted living is inappropriate for an independent client managing type 2 diabetes. It overlooks the client’s ability to live autonomously with support like telehealth, which is more suitable for rural settings to maintain independence and manage chronic conditions.

Choice D reason: Telehealth services enable rural clients with type 2 diabetes to access regular monitoring, education, and consultations, overcoming geographic barriers. This supports independent living, enhances glycemic control, and prevents complications, making it the most appropriate intervention for this client’s care plan.

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Click to highlight the findings that require immediate follow-up. (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an indication of paralytic ileus?

Correct Answer is C

Explanation

A community health nurse is developing a plan of care for an older adult client who has type 2 diabetes mellitus and lives independently in a rural area. Which of the following interventions should the nurse include?

Correct Answer is D

Explanation

A nurse is teaching a client who has major depressive disorder about what to expect when undergoing electroconvulsive therapy. Which of the following information should the nurse give the client?

A nurse is caring for a client who is preoperative for cataract removal. Which of the following statements by the client indicates an understanding of the procedure?

A nurse is performing an admission assessment of a school-age child who has spina bifida. The parent states that the child is allergic to latex. The nurse should assess further for cross-sensitivity to which of the following foods?

A nurse is observing an assistive personnel (AP) measure blood pressures from the right arms of a group of clients. The nurse should instruct the AP to measure the blood pressure in the left arm of which of the following clients?

A nurse is teaching the guardian of a newborn about car seat safety. Which of the following statements by the guardian indicates an understanding of the teaching?

While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm on the ventilator sounds. Which of the following actions should the nurse take?

A nurse is planning care for a client who is experiencing benzodiazepine toxicity. The nurse should plan to administer which of the following medications?

A nurse is teaching about how to suppress lactation with a client who is postpartum and bottle feeding their newborn. Which of the following instructions should the nurse include in the teaching?