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Patient's data

Exhibits
The nurse obtains verbal handoff from the outpatient clinic nurse, reviews the electronic health record, and completes an initial assessment including vital signs.

Which assessment findings require follow up by the nurse? Select all that apply.

Skin pale and diaphoretic

Respiratory rate 36 breaths/minute

Blood pressure 140/86 mm Hg

Temperature 101.1° F (38.4" C) orally

Bilateral basilar crackles

Bilateral radial pulses bounding

Heart rate 117 beats/minute and irregular

Oxygen saturation 98% on room air

Answer and Explanation

Correct Answer : A,B,C,D,E,G

A.   Skin pale and diaphoretic: These can be signs of dehydration, infection, or other conditions.
B.   Respiratory rate 36 breaths/minute - This is elevated, especially for a child, indicating potential respiratory distress or infection, particularly given the patient's history and current fever.
C.   Blood pressure 140/86 mm Hg - This is high for a 7-year-old and could indicate fluid overload or other complications related to his chronic kidney disease.
D.   Temperature 101.1° F (38.4° C) orally - Continued fever despite antipyretic treatment suggests ongoing infection or inflammation needing further evaluation.
E.   Bilateral basilar crackles - This could suggest fluid in the lungs (pulmonary edema), which is critical given the patient's possible fluid overload and high blood pressure.
F.   Bilateral bounding radial pulses is not necessarily a cause of concern in the above case.

G. Heart rate 117 beats/minute and irregular - An elevated and irregular heart rate in a child is concerning and could indicate cardiovascular stress or electrolyte imbalances, which need addressing given his elevated potassium levels.
H. Oxygen saturation 98% on room air: Normal oxygen saturation suggests adequate gas exchange.

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Correct Answer is ["A","C","D"]

Explanation

A. Weighing the client and reporting weight gain is within the scope of UAP and important for monitoring fluid retention and weight changes in Cushing's syndrome.

B. Assessing for weakness and fatigue requires clinical judgment and should be performed by a nurse.
C. Reporting any client mention of pain or discomfort is appropriate for UAP, as it involves relaying information to the nurse for further assessment.
D. Noting and reporting the client's food and liquid intake is appropriate for UAP and necessary for monitoring nutritional status and intake.
E. Evaluating sleep disturbances involves assessment skills and should be performed by a nurse.

A. Notify the charge nurse the client will need assignment to the COVID-19 specified area of the facility. B. Place the nasal swab specimen for COVID-19 directly into a biohazard bag. C. Start an intravenous infusion for antiviral drug to be administered for positive COVID- 19 test results. D. Maintain a 6 feet (1.8 meters) distance from the client unless wearing N95 respirator and personal protective equipment (PPE) for droplet precautions.

Correct Answer is D

Explanation

A. While important, immediate assignment to a COVID-19 area is secondary to infection control precautions.
B. Proper handling of the specimen is essential but secondary to immediate safety measures.
C. Starting antiviral drugs would only occur after a positive test result.

D. Maintaining a 6 feet distance and wearing appropriate PPE is the most important action to prevent transmission of the virus.

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Patient's data Exhibits The nurse obtains verbal handoff from the outpatient clinic nurse, reviews the electronic health record, and completes an initial assessment including vital signs. Which assessment findings require follow up by the nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is managing the care of a client with Cushing's syndrome. What intervention(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

Correct Answer is D

Explanation

106 A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?

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The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?

The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?

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An older adult client presents to the emergency department with abdominal pain due to constipation. The nurse is providing a list of high-fiber foods to the client that the healthcare provider has recommended. Which action should the nurse implement when reviewing the list of foods?

The healthcare provider prescribes 1 unit (350 mL) of packed red blood cells (PRBC) to infuse over 4 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter the numeric value only. Round to the nearest whole number.)

Patient's data

Exhibits
The nurse obtains verbal handoff from the outpatient clinic nurse, reviews the electronic health record, and completes an initial assessment including vital signs.

Which assessment findings require follow up by the nurse? Select all that apply.