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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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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Background music may be distracting rather than helpful during teaching.

B. Adequate lighting is crucial for older adults to clearly see and read instructional materials. However, overhead lights may be distracting and disorienting for an older adult.
C. Standing behind the client might actually increase feelings of intimidation or discomfort. It's better to face the client to facilitate communication.
D. Providing handouts written at a 12th grade reading level ensures that the information is accessible and understandable for the majority of adults.

A. Tell the child he will have to have a shot instead. B. Hide the medication in a large dish of ice cream. C. Tell the child it is candy. D. Offer the child a choice of taking the medication with juice or water.

Correct Answer is D

Explanation

A. Threatening the child with a shot may create anxiety and fear, making cooperation even more challenging.
B. Hiding medication in food without the child's knowledge can lead to mistrust and may not be safe, as the child may not consume the entire dose.
C. Misleading the child about the nature of the medication is not appropriate. It can lead to confusion and mistrust when the child realizes that it is not candy.

D. Providing choices empowers the child and makes the process of taking medication less intimidating. It also helps in engaging the child in their own care, making them feel more in control.

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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

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?

Correct Answer is D

Explanation

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?

Correct Answer is D

Explanation

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. What behavior(s) indicate the client understands how to maintain balance safely? Select all that apply.

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An older client is being admitted to a rehabilitation unit from a medical-surgical unit following a left hip replacement. When reviewing the client's prescribed medications, which intervention should the nurse implement first?

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.