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Exhibits

Select the 3 findings that require immediate follow-up by the nurse.

Mucus membranes

Integumentary findings

Emesis

Behavior

AST result

Vital signs

Movement of hands and fingers

Answer and Explanation

Correct Answer : B,D,F

A. Mucous membranes: Although they are noted to be dry, this alone is not an urgent finding. Mild dehydration may be monitored, especially when the client is stable and has IV access established.
B. Integumentary findings: Scratch marks and intense pruritus are consistent with cholestasis from liver dysfunction. This can lead to excoriation, infection, or indicate worsening hepatic failure, especially in the context of jaundice and elevated bilirubin.
C. Emesis: No vomiting or emesis is mentioned anywhere in the case details, making this an irrelevant and unsupported option for follow-up.
D. Behavior: The client is disoriented to time and displaying agitation with inappropriate language. In a client with alcohol use disorder and cirrhosis, this behavior can indicate the onset of hepatic encephalopathy which can rapidly progress and require immediate attention.
E. AST result: The AST level is significantly elevated (208 units/L), but liver enzymes are not immediate threats requiring urgent action. They confirm liver injury but do not direct acute intervention.
F. Vital signs: The client has a significantly elevated blood pressure (188/94 mmHg), tachycardia (120/min), and an increased temperature (38.4°C). These may reflect an acute withdrawal syndrome, sepsis, or intracranial injury—all of which demand urgent follow-up.
G. Movement of hands and fingers: There is no indication of tremors, asterixis, or motor deficits in the notes. Therefore, hand and finger movement does not currently present as a priority concern.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Wart-like texture: A wart-like texture is more typical of squamous cell carcinoma or benign lesions like seborrheic keratosis. Melanomas usually do not have a rough, wart-like surface.
B. Firm and rubbery: Firm, rubbery nodules are more consistent with benign skin growths such as dermatofibromas. Melanomas tend to have irregular texture and color rather than a uniform firmness.
C. A central crater with rolled borders: This description fits basal cell carcinoma, which often presents with a pearly nodule and central ulceration. Melanomas do not commonly have this crater-like appearance.
D. Asymmetric with variegated ring: Melanomas are typically asymmetric with uneven, irregular borders and multiple colors. This variegation and asymmetry are classic warning signs distinguishing melanoma from other lesions.

A. “Avoid high-fiber foods while taking this medication.” B. “Remove the patch for 8 hours every day to reduce the risk of tolerance." C. “Avoid hot tubs while wearing the patch.” D. “Apply the patch to your forearm.”

Correct Answer is C

Explanation

A. “Avoid high-fiber foods while taking this medication.”: Fentanyl can cause constipation, so a diet high in fiber is actually recommended to promote bowel regularity. Avoiding fiber would worsen one of the drug’s common side effects.
B. “Remove the patch for 8 hours every day to reduce the risk of tolerance.": Fentanyl patches are designed for continuous, 72-hour use. Removing the patch disrupts pain control and may lead to withdrawal symptoms or inadequate analgesia.
C. “Avoid hot tubs while wearing the patch.”: Heat exposure, including hot tubs or heating pads, can increase fentanyl absorption, potentially leading to overdose. Clients should be advised to avoid external heat sources near the patch.
D. “Apply the patch to your forearm.”: The patch should be applied to a flat, non-irritated area of the upper torso or upper arm. The forearm is not typically recommended due to its mobility and potential for detachment or reduced absorption.

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Exhibits Select the 3 findings that require immediate follow-up by the nurse.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a skin assessment on a client who has risk factors for the development of skin cancer. The nurse should understand that melanoma has which Of the following qualities?

Correct Answer is D

Explanation

A nurse is providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg/hr transdermal patch. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

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Exhibits

Select the 3 findings that require immediate follow-up by the nurse.