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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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Institutional policies and procedures: While institutional policies provide guidance on how tasks are performed within a facility, they cannot legally expand or limit a nurse’s scope of practice. Nurses must always ensure tasks are permitted by state law first.
B. Verbal direction from the nurse manager: Managers may offer direction, but their guidance should not override legal regulations. Relying solely on verbal instructions risks performing tasks outside the legal scope of practice, which can lead to liability issues.
C. State Nurse Practice Act: The Nurse Practice Act is a legal document specific to each state that defines the scope of practice for nurses. It outlines what tasks are legally permissible and serves as the most authoritative reference for professional responsibilities.
D. Written prescription from the provider: Although a provider can order treatments or procedures, nurses are still responsible for ensuring those actions fall within their legal scope. Following a prescription without verifying legality may result in practicing beyond licensure.

A. Insert the oral thermometer in front of the infant's tongue. B. Place the tip of the thermometer under the center of the infant's axilla. C. Pull the pinna of the infant's ear forward before inserting the probe. D. Insert the probe 3.8 cm (1.5 in) into the infant's rectum.

Correct Answer is B

Explanation

A. Insert the oral thermometer in front of the infant's tongue: Oral temperature is not recommended for infants due to the risk of injury and difficulty keeping the thermometer in place.
B. Place the tip of the thermometer under the center of the infant's axilla: The axillary route is safe and appropriate for infants. Ensuring the tip is in full contact with the skin in the center of the axilla ensures a more accurate reading.
C. Pull the pinna of the infant's ear forward before inserting the probe: For infants under 3 years, the pinna should be pulled down and back to straighten the ear canal, not forward.
D. Insert the probe 3.8 cm (1.5 in) into the infant's rectum: This depth is excessive for an infant; rectal insertion should be only about 1.3 to 2.5 cm (0.5 to 1 in) to avoid rectal trauma.

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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 newly licensed nurse is unsure if an assigned task is within their scope Of practice. Which Of the following resources should the nurse consult?

Correct Answer is C

Explanation

A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who is wearing antiembolic stockings. Which of the following interventions should the nurse include in the plan of care?

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A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first?

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Exhibits The nurse is reviewing the client's medical record. Select the 2 findings the nurse should identify as placing the client at risk for cardiovascular disease.

A nurse is caring for a client who speaks a different language than the nurse. Which of the following actions should the nurse take when communicating with the client?

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

Exhibits

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