Exhibits

The nurse reviews the client’s medical record from admission to 1930 hrs. Click to indicate whether the assessment finding has improved or not changed.

Dyspnea

Heart rate

Blood pressure

Oxygen saturation

Respiratory rate

Oral intake

Lung sounds

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"B"}}

Assessment Finding	Improved	No change
Dyspnea		✅
Heart rate	✅
Blood pressure	✅
Oxygen saturation	✅
Respiratory rate	✅
Oral intake	✅
Lung sounds		✅

Rationale:

Improved:

Heart rate and blood pressure are slightly improved by 1930, likely due to the medications (furosemide, enalapril) helping manage fluid retention and blood pressure.

Oral intake has improved, but monitoring of this is critical given the recent lack of eating for several days.

No change:

Dyspnea remains unchanged, since the adolescent is still dyspneic with activity.

Lung sounds remain unchanged, indicating that there may still be some wheezing or fluid buildup in the lungs.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Elevating the casted arm helps reduce swelling and promotes circulation. The arm should be elevated above the heart level when resting to minimize swelling.

B. Immobilizing the shoulder is unnecessary unless specifically instructed, as immobilizing the shoulder is not required for most arm fractures.

C. Swelling of the fingers can occur with a cast, but it should not last longer than 24 hours. Prolonged swelling should be reported.

D. Allowing the limb to hang down may increase swelling and should be avoided.

A. Abdominal pain rated 4 on a scale of 0 to 10 B. Respiratory rate 20/min. C. Blood pressure 93/50 mm Hg D. Heart rate 72/min

Correct Answer is C

Explanation

A. Abdominal pain rated 4 is moderate and should be managed but is not as immediately critical as hypotension.

B. A respiratory rate of 20/min is within normal limits for an adolescent and is not a priority finding.

C. Low blood pressure (hypotension) following blunt abdominal trauma is a concern for internal bleeding or hemorrhage. This is the priority finding and requires immediate intervention.

D. A heart rate of 72/min is normal and does not indicate immediate concern.

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Exhibits The nurse reviews the client’s medical record from admission to 1930 hrs. Click to indicate whether the assessment finding has improved or not changed.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is conducting teaching to parents of a 7-year-old child who fractured an arm and is being discharged with a cast. Which instruction would be included in the teaching?

Correct Answer is A

Explanation

A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the following findings is the nurse's priority?

Correct Answer is C

Explanation

A nurse is educating caregivers about dietary management for a child who has burn injuries. Which of the following recommendations should the nurse provide?

A nurse is assessing the pain level of a 3-year old toddler. Which of the following pain assessment scales should the nurse use?

A nurse is teaching a newly hired nurse about the management of care for the terminal illness of a child. Which of the following statements by the newly hired nurse indicates an understanding of the teaching?

A nurse is caring for an infant who has inadequate motility of part of the intestine resulting in a mechanical obstruction. The nurse should identify this finding as a manifestation of which of the following disorders?

A nurse is caring for an 8-year-old child who has acute rheumatic fever. Which of the following assessments is the nurse's priority immediately after admission?

A nurse is receiving change of shift report on four children. Which of the following children should the nurse assess first?

A nurse in a special education program is planning care for a child who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan of care?

Exhibits

The nurse reviews the client’s medical record from admission to 1930 hrs. Click to indicate whether the assessment finding has improved or not changed.