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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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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Petroleum jelly should not be used around the nose of a toddler receiving oxygen due to the risk of aspiration and the potential for oxygen to ignite the jelly.

B. Topical lidocaine is not appropriate for cracked lips, as it can cause numbness and possibly interfere with the child's ability to protect their airway.

C. Asking the mother is a good communication approach, but the nurse should also take immediate action to address the dryness using an appropriate lubricant.

D. Use a water-soluble lubricant on affected oral and nasal mucosa is the most appropriate intervention, as petroleum jelly can be harmful if inhaled, and a water-soluble lubricant is safer for use in the nasal and oral areas, especially in young children.

A. Feelings of disorientation. B. Undiagnosed social anxiety symptoms (SAD). C. Family history of schizophrenia. D. History of suicide attempts.

Correct Answer is D

Explanation

A. Feelings of disorientation may be a symptom of heroin use, but addressing the client’s mental health, particularly suicidal tendencies, takes precedence.
B. Undiagnosed social anxiety symptoms may be important for long-term care, but the immediate concern is the risk of self-harm or overdose.
C. Family history of schizophrenia is relevant for mental health but does not take priority over assessing suicide risk in a client using heroin.
D. A history of suicide attempts is crucial for the nurse to consider because individuals using heroin may be at an increased risk of self-harm due to the psychological effects of substance use and potential for overdose. Immediate safety and suicide risk assessment are critical.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While caring for a toddler receiving oxygen via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?

Correct Answer is D

Explanation

During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

Correct Answer is D

Explanation

The nurse is completing the admission assessment of a client with multiple sclerosis (MS). Which finding(s) should be reported to the healthcare provider immediately? Select all that apply.

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

A female client presents to the clinic with a fever and sore throat as well as a rash on the hands, palms, and the soles of the feet. The client reports having intercourse once with a new partner approximately 8 weeks ago. Which condition should the nurse suspect?

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?

Patient Data

Exhibits

Select the 4 assessment findings that require immediate follow up.