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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

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

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

D. This practice is recommended as a safety precaution to minimize the risk of radioactive contamination following treatment with radioactive isotopes. It helps to ensure that any residual radioactivity is contained and not inadvertently spread, which is particularly important in shared or public bathrooms.

A The recommended distance is typically at least 1 meter (approximately 3 feet), although specific guidelines may vary depending on the type and dose of radiation used.

B. The use of cloth handkerchiefs versus disposable tissues does not significantly affect radiation safety. The focus should be on minimizing contamination and ensuring proper disposal of any tissues or materials that come into contact with bodily fluids.

C. While managing incontinence appropriately is important for comfort and hygiene, it is not directly related to radiation safety. Clients should use standard incontinence products as needed, ensuring proper disposal and hygiene practices.

A. "Wait 30 seconds between puffs." B. "The spacer should make a whistling sound as you inhale." C. "Clean the spacer daily with cold water." D. "Hold your breath for 10 seconds once you inhale."

Correct Answer is D

Explanation

D. After inhaling the medication, holding the breath for about 10 seconds allows the medication to settle in the lungs and be absorbed effectively into the bloodstream. This improves the medication's effectiveness in controlling asthma symptoms.

A Waiting 30 seconds between puffs is not a standard instruction; instead, it is generally advised to wait about one minute between puffs if multiple doses are needed.

B. The whistling sound may indicate that the client is inhaling too quickly or forcefully, which can prevent the medication from reaching the lungs effectively.

C. Cleaning the spacer is also crucial, but it is typically recommended to use warm soapy water rather than cold water, and it should be left to air dry.

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 is providing teaching to a group of clients who are receiving radioactive isotope therapy. Which of the following information should the nurse include?

Correct Answer is D

Explanation

A nurse is teaching a client who has asthma about how to use a metered-dose inhaler with a spacer. Which of the following information should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is caring for a client in the ICU. The client's ECG monitor tracing reveals sinus bradycardia and S-T segment elevation. The client reports shortness of breath and feeling dizzy and faint. Which of the following medications should the nurse administer?

A nurse is administering furosemide 80 mg PO twice daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective?

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

A PACU nurse is monitoring the drainage from a client's NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider?

A nurse is providing teaching to a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication?

A nurse is assessing a client who is 4 hr postoperative following arterial revascularization of the left femoral artery. Which of the following findings should the nurse report to the provider immediately?

A nurse is caring for a client immediately following a cardiac catheterization through the right femoral artery. Which of the following actions should the nurse take?

A nurse is assessing a client following the administration of an initial dose of captopril. Which of the following findings indicates an anaphylactic response?

Exhibits

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