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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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. This task typically requires a more advanced level of clinical judgment and assessment skills, which are usually beyond the scope of practice for a PN and should be conducted by a Registered Nurse (RN).
B. Removing discontinued peripheral IV catheters is a task that falls within the scope of practice for a Practical Nurse (PN). It does not require the advanced assessment skills or judgment that some other tasks might require.
C. This involves critical thinking and clinical decision-making that are responsibilities typically reserved for an RN, as it requires integrating new information and adjusting care plans based on ongoing assessments.
D. While PNs can perform certain types of wound care, initiating sterile wound care for surgical clients often requires the advanced knowledge and assessment skills of an RN, particularly if the wound care involves evaluating surgical site integrity and potential complications.

A. Ask the client to describe the pain. B. Identify effective pain relief measures. C. Observe body language and movement. C. Provide a numeric pain scale.

Correct Answer is A

Explanation

A. Asking the client to describe the pain allows for a detailed assessment of the pain's quality, location, intensity, and any aggravating or alleviating factors. This information is crucial for tailoring pain management strategies to the client's specific needs.
B. Identifying effective pain relief measures is important but comes after understanding the pain's characteristics.
C. Observing body language and movement can provide clues about pain but is subjective and less accurate than direct communication.
D. A numeric pain scale measures pain intensity but does not provide information about the quality or nature of the pain.

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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

After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

Correct Answer is B

Explanation

A client with metastatic bone cancer is requesting pain medication. Which approach should the nurse use to assess the quality of the client's pain?

Correct Answer is A

Explanation

During discharge teaching, an overweight client with heart failure (HF) is asked to make a grocery list for the nurse to review. What food choice(s) included on the client's list should the nurse encourage? Select all that apply.

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

A nurse is caring for a 4-year-old child who is resistant to taking medication. Which of the following strategies should the nurse use to elicit the child's cooperation?

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In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

A client who is participating in an anger management assignment asks to make a leather belt in occupational therapy. The client begins pounding the leather vigorously with a mallet to imprint designs on the belt. Which defense mechanism is the client using?

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.