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Exhibits
The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.

Bone misalignment

Decreased range of motion

Left arm that is cool to touch

Swelling at the site of injury

Blood pressure of 136/90 mm Hg

Intense pain reported by client

Oxygen saturation 95% on room air

Answer and Explanation

Correct Answer : A,B,C,D,F

A. Bone misalignment - The nurse’s notes mention that the collarbone appears out of alignment on the left side. This could indicate a fracture or dislocation and should be investigated further.

B. Decreased range of motion - The client reports an inability to move his left arm. This could be due to the pain or a result of the injury and should be investigated further.

C. Left arm that is cool to touch - Decreased temperature in a limb can indicate poor circulation, which could be a result of the injury. This should be investigated further.

D. Swelling at the site of injury - Swelling and bruising are present on the client’s shoulder. This is a common sign of injury and should be investigated further.

E. Blood pressure of 136/90 mm Hg - While this blood pressure is not extremely high, it is on the higher end of normal. Given the client’s age and the stress of the situation, it would be worth monitoring.

F. Intense pain reported by client - The client reports a pain rating of 10 on a 0 to 10 scale in the left arm. This level of pain is concerning and should be addressed.

G. Oxygen saturation 95% on room air - While an oxygen saturation of 95% is within the normal range, given the client’s recent trauma and reported nausea, it would be prudent to monitor this closely.

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Correct Answer is B

Explanation

Choice A rationale

Determining the amount of weight the patient has lost since increasing activity is relevant to the patient’s overall health and progress toward weight loss goals, but it does not directly address the issue of sleep difficulties. Weight loss and improved sleep may not always have a direct cause-and-effect relationship.

Choice B rationale

Inquiring about the patient’s exercise schedule is a reasonable action. It allows the nurse to gather information about the patient’s exercise routine and assess whether it might be contributing to the sleep difficulties. For instance, exercising too close to bedtime can interfere with sleep. Therefore, understanding the timing and intensity of the patient’s exercise can provide valuable insights into potential adjustments that could improve sleep quality.

Choice C rationale

Informing the patient that lifestyle changes often take several weeks to be effective is a general statement that might not address the specific concerns of the patient. While it’s true that lifestyle changes, including exercise, can take time to show results, this does not provide a targeted solution to the patient’s reported difficulty in falling asleep.

Choice D rationale

Encouraging the patient to exercise daily to reduce bedtime wakefulness is not appropriate advice in this scenario. It oversimplifies the issue and may not address the underlying causes of the patient’s sleep difficulties. Additionally, excessive exercise close to bedtime may actually interfere with sleep.

A. Diarrhea and flatulence. B. Abdominal cramps. C. Altered taste. D. Muscle pain.

Correct Answer is D

Explanation

Choice A rationale

Diarrhea and flatulence are common side effects of lovastatin, but they are not typically serious enough to require immediate follow-up.

Choice B rationale

Abdominal cramps can occur with lovastatin use, but they are not usually a sign of a serious problem.

Choice C rationale

Altered taste is a less common side effect of lovastatin and is not typically a cause for immediate concern.

Choice D rationale

Muscle pain can be a sign of a rare but serious side effect of lovastatin called rhabdomyolysis. This condition involves the breakdown of muscle tissue, which can lead to kidney damage. Therefore, this symptom should be prioritized for immediate follow-up.

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Exhibits The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient informs the nurse about starting an exercise program a month ago to lose weight and improve sleep.The patient states, “It still takes at least two hours to fall asleep at night.”. What action should the nurse take?

Correct Answer is B

Explanation

Which of the following symptoms reported by a patient taking lovastatin should the nurse prioritize for immediate follow-up?

Correct Answer is D

Explanation

Exhibits After the nurse assesses the client, the healthcare provider writes prescriptions. The nurse reviews the prescriptions. Which 2 prescriptions should the nurse complete first?

A nurse is assessing a 3-month-old patient who underwent a pyloromyotomy the previous day.Which of the following findings would indicate a need for pain medication? Select all that apply.

A straight catheter produced 500 mL of clear yellow urine. For each finding, indicate whether the findings suggest that the client’s condition has improved or put the client at risk for hypovolemia. Each column must have at least one selection.

After traveling to a country with a tropical climate, a young adult is diagnosed with a liver abscess and is taking antimicrobial therapy as an outpatient.During a follow-up visit at the community clinic, the nurse observes that the patient has developed jaundice.Which action should the nurse take?

Exhibits
The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.