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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.

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Correct Answer is D

Explanation

A. Reinflating the cuff to a higher number may not resolve the issue and can lead to unnecessary discomfort.

B. An auscultatory gap occurs when Korotkoff sounds disappear temporarily after being heard and then reappear. Here, the scenario describes silence followed by the first Korotkoff sound,which is normal, not a gap.

C. Repositioning the stethoscope over the brachial artery may not help if the auscultatory gap is the issue.

D. When measuring blood pressure, it is normal to first hear silence after inflation until the pressure in the cuff falls just below the systolic pressure, at which point the first Korotkoff sound appears. That first sound marks the systolic blood pressure. Therefore, the nurse should continue deflating the cuff and completing the measurement to identify both systolic and diastolic pressures accurately.

A. The client's daily blood pressure will be less than 140/80 mm Hg this month. B. The client's family will state signs and symptoms about the disease. C. The nurse will demonstrate the procedure for accurate eye care. D. The client will express acceptance of his changing health status.

Correct Answer is A

Explanation

A: Controlling blood pressure to less than 140/80 mm Hg is essential for reducing the risk of diabetic retinopathy, which can contribute to blurred vision and other complications.

B: Educating the family about the disease is important, but it does not directly address the client’s blurred vision or its underlying cause.

C: While eye care is important, this outcome does not focus on addressing the underlying issue of blurred vision in a client with diabetes.

D: Although acceptance of health status is important, it is not as directly related to managing the client’s vision issues as controlling blood pressure.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

Correct Answer is D

Explanation

The nurse is developing a plan of care for an older male client with type 2 diabetes who reports blurred vision. Which outcome should the nurse include in the plan of care for this client?

Correct Answer is A

Explanation

After the nurse witnesses a preoperative client signing the surgical consent form, the nurse signs the form as a witness. Which is (are) the legal implication(s) of the nurse's signature on the client's surgical consent form? Select all that apply.

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

A client's catheter bag was left on the client's bed for a prolonged period of time, and the client develops a urinary tract infection (UTI). In evaluating the cause of the infection, which should the nurse identify as the infection reservoir?

The home health nurse makes a home visit to a client with amyotrophic lateral sclerosis (ALS). The client is sitting upright while feeding themself and coughs frequently during the meal. Which action should the nurse implement?

Exhibits The client has started to wake up more, opening her eyes without stimulation and looking around the room. Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.

A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instruction(s) should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Select all that apply.

Patient Data

Exhibits

Select the 4 assessment findings that require immediate follow up.