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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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Correct Answer is B

Explanation

A. Leave the room to initiate a rapid response: Leaving the client alone during a seizure places them at high risk for injury. The nurse should remain with the client to provide immediate safety interventions and call for help without leaving the bedside.
B. Loosen any clothing around the client's neck: Loosening clothing helps maintain an open airway and reduces the risk of choking or airway obstruction during the seizure, making it a priority intervention.
C. Place the client in a high-Fowler’s position: High-Fowler’s position is inappropriate during a seizure because it increases the risk of falling or injury. The client should be placed on their side to promote drainage of secretions and reduce aspiration risk.
D. Apply a bite block in the client's mouth: A bite block should never be inserted during an active seizure due to the risk of injuring the mouth or airway. It can only be used before a seizure in specific circumstances, if prescribed.

A. Transport the client to another area of the nursing unit. B. Activate the facility’s fire alarm system. C. Use the unit’s fire extinguisher to attempt to put out the fire. D. Close all nearby windows and doors.

Correct Answer is A,B,D,C

Explanation

A. The first priority is to rescue any individuals in immediate danger. Moving the client ensures their safety before addressing the fire. Delaying this step could expose the client to smoke inhalation or burns.

B. Once the client is safe, the nurse must activate the fire alarm system. This alerts the rest of the facility and triggers the emergency response protocol. Early alarm activation helps prevent the fire from spreading further.

C. Attempting to extinguish the fire comes only after other safety measures. If the fire is small and controllable, using a fire extinguisher may prevent escalation. However, it must only be attempted when it is safe to do so.

D. Closing nearby windows and doors helps contain the fire to one area. This reduces oxygen flow and slows the spread of fire and smoke throughout the unit. Containment is a key step in minimizing damage and injury.

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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 caring for a client who has just started having a seizure. Which of the following interventions should the nurse implement?

Correct Answer is B

Explanation

28. A nurse enters a client's room and sees a small fire in the client's bathroom. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps) (ORDERED RESPONSE)

Correct Answer is A,B,D,C

Explanation

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Exhibits

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