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Patient Data

Exhibits

Select the 4 assessment findings that require immediate follow up.

Severe abdominal pain in right lower quadrant

Blood pressure 115/76 mm Hg

Capillary refill 2 seconds

Radial and pedal pulses 2+1

Temperature 100.8° F (38.2° C)

Respirations 28 breaths/minute with shallow breathing

Feels anxious

Heart rate 121 beats/minute

Vomiting small amounts of green bile

Answer and Explanation

Correct Answer : A,E,F,H

A. Severe abdominal pain in the right lower quadrant: This could indicate appendicitis, a surgical emergency, or another acute abdominal condition requiring immediate intervention. The sudden onset and severe nature of pain are concerning.
B. Blood pressure 115/76 mm Hg: This is within normal limits and does not indicate immediate instability.
C. Capillary refill 2 seconds: This indicates adequate peripheral perfusion and is not an urgent concern.
D. Radial and pedal pulses 2+: Normal peripheral pulses do not require immediate follow-up.
E. Temperature 100.8° F (38.2° C): Fever suggests an inflammatory or infectious process, such as appendicitis or another intra-abdominal infection.
F. Respirations 28 breaths/minute with shallow breathing: Increased respiratory rate and shallow breathing may indicate pain-related distress or developing peritonitis, a life-threatening complication of appendicitis.
G. Feels anxious: Anxiety may be a response to pain but is not an immediate concern requiring urgent intervention.
H. Heart rate 121 beats/minute: Tachycardia could be a response to pain, infection, or developing sepsis, which requires urgent evaluation.
I. Vomiting small amounts of green bile: While bile-stained emesis can indicate an obstruction, other findings (pain, fever, tachycardia, and respiratory distress) are higher priority.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Exenatide does not act exactly the same as insulin. It is a glucagon-like peptide-1 (GLP-1) receptor agonist, not insulin.

B. Notify your healthcare provider if you start having abdominal pain is important because abdominal pain is a known side effect of exenatide and may indicate a more serious issue like pancreatitis, which needs to be addressed promptly.

C. There are precautions when taking exenatide with other medications, especially those that affect gastrointestinal motility or glucose levels, so this statement is incorrect.

D. Exenatide should be injected within 60 minutes before a meal, not 30 minutes before or after, to optimize its effectiveness.

A. Administer PRN oral analgesics to a client with a history of chronic pain. B. Supervise a newly hired graduate nurse during an admission assessment. C. Transport a client who is receiving IV fluids to the radiology department. D. Complete ongoing focused assessments of a client with wrist restraints.

Correct Answer is B

Explanation

A. Administering PRN oral analgesics is within the scope of a PN’s responsibilities and does not require an RN’s expertise.
B. The RN is responsible for supervising other nurses, including newly hired graduate nurses, and ensuring that assessments are performed competently.
C. Transporting a client is typically a task for a UAP, as long as it does not require complex nursing interventions.
D. Focused assessments of clients with wrist restraints can be performed by both an RN and a PN, but this is generally within the scope of the PN’s duties.

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Patient Data Exhibits Select the 4 assessment findings that require immediate follow up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning discharge instructions for a client with type 2 diabetes mellitus who will be starting exenatide. Which information should be included in the discharge instructions?

Correct Answer is B

Explanation

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?

Correct Answer is B

Explanation

Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. Which action should the nurse take?

The psychiatric nurse is talking to a newly admitted client when another male client, who is diagnosed with antisocial behavior, intrudes on the conversation and tells the nurse, "I have to talk to you right now! It is very important!" How should the nurse respond to this client?

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

An client who weighs 160 pounds receives a prescription for gentamicin 5 mg/kg/day IV in divided doses every 8 hours. How many mg should the nurse administer with each dose? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Following a bowel resection, a client's tympanic temperature was 97.6° F (36.4° C) on admission to the postanesthesia care unit (PACU). Thirty minutes later, the temperature is 101.6°F (38.7° C). Which intervention(s) should the nurse implement? Select all that apply.

The nurse assesses a client who had bilateral total knee replacements (TKR) four hours ago. The nurse notes that the dressing on the client's right knee is saturated with serosanguineous drainage. Which action should the nurse implement?

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Patient Data

Exhibits

Select the 4 assessment findings that require immediate follow up.