Try Naxlex NCLEX-RN (Free-Trial)

Exhibits

The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up:

Blood glucose level

Bowel sounds

Blood pressure

Pain level

Electrocardiogram findings

Lung sounds

Troponin T level

Answer and Explanation

Correct Answer : C,D,E,G

C. The blood pressure readings show significant variability (164/80 mm Hg at 1000, 176/82 mm Hg at 1015, and 110/62 mm Hg at 1200). These fluctuations, especially the higher readings, indicate potential instability and require close monitoring and possibly intervention.
D. The client's pain level is described as 7/10 initially (1000) and decreases to 5/10 after nitroglycerin (1200). Although the pain has decreased, ongoing assessment is necessary to ensure it does not worsen or change in nature.
E. The 12-lead electrocardiogram (ECG) shows tachycardia with ST segment elevation and T wave changes, which are indicative of myocardial ischemia or infarction. This finding requires immediate attention as it suggests ongoing cardiac damage.
G. The troponin T level is elevated at 0.40 ng/mL (normal is less than 0.1 ng/mL). Troponin elevation indicates myocardial injury or infarction and confirms the seriousness of the cardiac event. This finding requires immediate attention to assess the extent of myocardial damage and guide further treatment.

Incorrect Choices
A. While it is slightly elevated, it is not significantly outside the normal range and does not suggest immediate danger or require urgent intervention in the context of the acute cardiac issue. However, monitoring blood glucose levels is important for overall management, especially in a client with diabetes mellitus.
B. The assessment of bowel sounds being present in all 4 quadrants is a normal finding and indicates normal gastrointestinal function. While bowel sounds are important for assessing gastrointestinal health, they are not immediately pertinent to the acute cardiac issue described in the scenario.
F. The nurse notes that lung sounds are clear to auscultation in all lobes, which is a normal finding. Clear lung sounds suggest normal respiratory function and do not require immediate attention in the context of the acute cardiac event described.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A Pertussis is highly contagious and spread through respiratory droplets. Wearing a surgical mask when providing care to the client helps prevent the spread of the bacteria to others in the healthcare setting. This is a standard precaution to minimize transmission of respiratory infections.

B. A Mantoux test, or tuberculin skin test, is used to detect tuberculosis (TB) infection, not pertussis. It is not relevant to the diagnosis or management of pertussis. The focus should be on clinical assessment and appropriate treatment for pertussis.

C Pertussis does not typically require isolation in a negative pressure airflow room. Standard precautions, including wearing a surgical mask, are generally sufficient to prevent transmission. Negative pressure rooms are typically reserved for airborne infections like tuberculosis or measles.

D. Pertussis is caused by a bacterial infection (Bordetella pertussis), not a virus. Antiviral therapy is not effective against bacterial infections such as pertussis. Family members and close contacts of the client should receive prophylactic antibiotics to prevent spread of the infection, not antiviral therapy.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

The nurse should administer a total 1320ml sodium chloride in the first hour, 880ml each subsequent hour.

Rationale

First Hour Administration

Rate: 15 ml/kg/hr Client's weight: 88 kg

Calculation: 15 ml/kg/hr × 88 kg= 1320ml/hr

Therefore, in the first hour, the nurse should administer 1320 mL of 0.9% sodium chloride.

Subsequent Hour Administration

Rate: 10 ml/kg/hr Client's weight: 88 kg

Calculation: 10 ml/kg/hr × 88kg= 880mls

Therefore, each subsequent hour after the first, the nurse should administer 880 mL of 0.9% sodium chloride.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Exhibits The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse working in the emergency department is admitting a client who has pertussis. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

Exhibits Complete the following sentence by using the lists of options. The nurse should administer a total dropdown sodium chloride in the first hour, dropdown each subsequent hour.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

First Hour Administration

Subsequent Hour Administration

A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include?

A nurse is caring for a client who has end-stage liver disease and is being placed on a transplant list. Which of the following statements by the client is the priority for the nurse to report to the provider?

A charge nurse on a neurological unit is making room assignments for a group of clients. Which of the following clients should the nurse assign to the room closest to the nurses' station?

A nurse is planning the discharge of a client who had an ischemic stroke. The nurse should ensure that the client is discharged with which of the following types of pharmacologic therapy?

A nurse is caring for a client who has oral achalasia. The nurse should ask the client which of the following questions to assess their ability to swallow?

A nurse is caring for a client who is postoperative and develops respiratory depression after receiving morphine for pain control. Which of the following medications should the nurse expect the provider to prescribe?

Exhibits A nurse is reviewing the client's diagnostic results and vital signs. Which of the following actions should the nurse take?

Exhibits

The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up: