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Patient Data

Exhibits

The nurse is reviewing the client's initial assessment findings.
Which assessment findings require follow-up? Select all that apply.

IV site without redness or swelling

Temperature: 98.8° F (37.1° C)

Respirations: 28 breaths/minute

Heart rate: 92 beats/minute

Taking shallow breaths

Alert and oriented to person, place, time and situation

Pain 8 on a 0 to 10 scale

Blood pressure: 138/82 mm Hg

Answer and Explanation

Correct Answer : C,E,G

A. IV site without redness or swelling: The IV site appears normal with no signs of infiltration or infection, so no immediate follow-up is required. This finding indicates proper IV insertion and maintenance.

B. Temperature: 98.8° F (37.1° C): This is within normal limits and does not indicate fever or infection, so it does not require immediate follow-up.

C. Respirations: 28 breaths/minute: This is above the normal adult range (12–20 breaths/minute) and may indicate respiratory distress due to pain, shallow breathing, or possible pulmonary complications such as atelectasis or pneumonia, requiring close monitoring and follow-up.

D. Heart rate: 92 beats/minute: Slightly elevated but within mild tachycardia range, which could be related to pain or anxiety. It should be monitored but does not require urgent follow-up.

E. Taking shallow breaths: Shallow breathing is concerning in a client with rib fractures, as it increases the risk for hypoventilation, atelectasis, and pneumonia. This requires immediate intervention, such as pain management and respiratory support.

F. Alert and oriented to person, place, time, and situation: Cognitive status is normal, so no follow-up is needed.

G. Pain 8 on a 0 to 10 scale: Severe pain limits deep breathing and mobility, increasing the risk of complications. Pain management should be addressed promptly to improve comfort and respiratory function.

H. Blood pressure: 138/82 mm Hg: Slightly elevated, likely related to pain or stress. Monitor trends, but it does not require immediate follow-up at this time.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Rationale for correct choices:

• Pain: The client reports a pain level of 10/10 in the left arm, described as sharp and constant. Pain at this severity requires urgent management because uncontrolled pain can impair mobility. Immediate intervention for pain ensures comfort and supports further diagnostic and therapeutic procedures.

• Compartment syndrome: Findings of swelling, decreased sensation, coolness of the skin, and diminished left radial pulse suggest compromised circulation. These are classic warning signs of compartment syndrome, a limb-threatening complication caused by increased pressure within a muscle compartment.

Rationale for incorrect choices:

• Mobility: While the client’s long-term recovery will require mobility interventions, it is not the immediate priority in the acute emergency setting. Pain and neurovascular compromise take precedence over mobility at this stage because they directly affect safety and circulation.

• Swelling: Swelling is a significant concern, but it is a symptom rather than the priority need. Addressing pain and preventing complications such as compartment syndrome will indirectly reduce swelling by improving circulation and managing tissue injury.

• Venous thromboembolism: The client’s high BMI and reduced mobility put him at risk for VTE, but this is a longer-term complication. It does not outweigh the immediate need to manage severe pain and monitor for compartment syndrome, which can cause rapid tissue necrosis.

• Fat embolism syndrome: Fat embolism is a possible complication of long bone fractures, but there is no evidence here of a femoral fracture or respiratory distress. Although his weight and orthopedic history are risk factors, the current findings point more strongly toward compartment syndrome.

A. Urinate immediately into a urinal, and the laboratory will collect the specimen every 6 hours, for the next 24 hours. B. Cleanse around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle. C. For the next 24 hours, notify nurse when the bladder is full, and the nurse will collect catheterized specimens. D. Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours.

Correct Answer is D

Explanation

A. Urinate immediately into a urinal, and the laboratory will collect the specimen every 6 hours, for the next 24 hours: Intermittent collection is not used for a 24-hour urine test; continuous collection of all urine after the start time is required to accurately measure creatinine clearance.

B. Cleanse around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle: This procedure is for a clean-catch or midstream urine specimen, not a 24-hour collection, and does not provide the total volume needed for creatinine clearance.

C. For the next 24 hours, notify nurse when the bladder is full, and the nurse will collect catheterized specimens: Catheterization is unnecessary for routine 24-hour urine collection and increases infection risk. The client can collect urine in a provided container.

D. Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours: Discarding the first void establishes the start of the collection period, and collecting all urine for the next 24 hours ensures accurate measurement of creatinine clearance.

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Patient Data Exhibits The nurse is reviewing the client's initial assessment findings. Which assessment findings require follow-up? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. Based on the client's condition, the priority need will be to address dropdown. In addition, he will need interventions to prevent dropdown_.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

The nurse plans to collect a 24 hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?

Correct Answer is D

Explanation

A parent brings their child, who has a history of asthma, to the emergency department (ED). The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain?

The nurse is performing a musculoskeletal assessment with a client. Which action(s) should the nurse implement when performing passive range of motion (PROM) exercises with a client? Select all that apply.

A 3-year-old client was successfully toilet trained prior to admission to the hospital for injuries sustained from a fall. The client's parents are very concerned that the child has regressed in toileting behaviors. Which information should the nurse provide to the parents?

A client with a history of alcohol addiction says, "My body feels fine when I abstain from alcohol consumption, but I miss my late night glasses of wine." Which concept should the nurse discuss with the client?

The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?

Which task should the nurse delegate to an unlicensed assistive personnel (UAP)?

When preparing to administer an intravenous medication through a client's triple lumen central venous catheter, the nurse observes that there are no continuous intravenous fluids infusing. Which action should the nurse take?

Patient Data

Exhibits

The nurse is reviewing the client's initial assessment findings.
Which assessment findings require follow-up? Select all that apply.