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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 ["A","B","E"]

Explanation

A. Wear a dosimeter film badge to measure exposure: The dosimeter badge tracks cumulative radiation exposure to ensure the nurse stays within safe limits. It is essential personal protective equipment when caring for clients undergoing internal radiation therapy.
B. Place a caution sign on the client’s door: A radiation warning sign alerts staff and visitors about the presence of a radioactive source, ensuring they follow safety protocols to minimize unnecessary exposure.
C. Discard bed linens from the client's room at the end of each day: Linens are not contaminated by a sealed implant, as the radiation source is enclosed and does not leak into the environment. Linens should be handled per routine procedure unless visibly soiled.
D. Instruct visitors to remain 61 cm (2 feet) away from the client: Visitors should be instructed to stay at least 6 feet (approximately 183 cm) away and limit visits to 30 minutes. The 2-foot distance is insufficient to ensure safety from radiation exposure.
E. Don a lead apron when providing care: A lead apron helps shield the nurse from radiation exposure when close contact is necessary. It is a standard precaution when interacting with clients who have a sealed radiation source.

A. Bowel movement 5 days ago B. Pupil diameter 6 mm C. Blood pressure 80/40 mm Hg D. Urinary output 120 mL/4 hr

Correct Answer is C

Explanation

A. Bowel movement 5 days ago: Constipation is a common side effect of morphine and should be addressed, but it is not immediately life-threatening and can be managed with laxatives or stool softeners.
B. Pupil diameter 6 mm: Pupil dilation is not a typical concern with morphine; miosis (constriction) is more commonly expected. While abnormal pupil size can indicate neurologic or drug-related issues, hypotension takes priority here.
C. Blood pressure 80/40 mm Hg: Hypotension is a serious adverse effect of morphine that may indicate circulatory depression. It requires immediate intervention to prevent inadequate organ perfusion and potential shock.
D. Urinary output 120 mL/4 hr: This output equals 30 mL/hr, which is within the expected minimum range. No immediate intervention is required, though continued monitoring is appropriate.

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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 a sealed radiation implant. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

A nurse is assessing a client who is receiving morphine IV for pain. Which of the following findings should the nurse report to the provider first?

Correct Answer is C

Explanation

A nurse is caring for a client who is obese. The client is crying and states. "Everyone is staring at me because of my weight." Which of the following responses should the nurse make?

A nurse is training a newly licensed nurse. The newly licensed nurse asks if she can delegate the task of weighing several clients to an assistive personnel (AP). Which of the following responses should the nurse make?

165. A nurse is collecting a specimen for an aerobic culture from a client who has a draining pressure injury. Identify the sequence of actions the nurse should follow. (Move the Steps into the box on the right. placing them in the order of performance. use all the steps.)

A nurse is planning to teach a group of newly licensed nurses about hypernatremia. Which of the following manifestations should the nurse include in the teaching?

A nurse is caring for a client who is in labor and has received an epidural. Which of the following actions should the nurse take?

A charge nurse is educating a newly licensed nurse about fluid and electrolyte balance. Which of the following manifestations should the newly licensed nurse identify as a sign of magnesium sulfate toxicity?

A nurse reviews the provider prescriptions and reassesses the client. Exhibits The nurse is continuing to care for the client. Which of the following actions should the nurse take? Select all that apply.

Exhibits

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