Which descriptions of stool warrant additional follow-up by the nurse? (Select all that apply.).

Solid with red streaks.

Formed but soft.

Brown liquid.

Tarry appearance.

Multiple hard pellets.

Answer and Explanation

Correct Answer : A,C,D,E

A. Solid stool with red streaks may indicate lower gastrointestinal bleeding and requires further evaluation.
B. Formed but soft stool is a normal finding and does not require follow-up.
C. Brown liquid stool may suggest diarrhea or malabsorption issues, warranting further assessment.
D. A tarry appearance can indicate upper gastrointestinal bleeding and requires prompt follow-up.
E. Multiple hard pellets may indicate constipation or dehydration and should be addressed.

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Correct Answer is B

Explanation

Hyperkalemia is a condition where there is an elevated level of potassium in the blood.

It can occur in patients with renal disease due to the kidneys’ reduced ability to excrete potassium.

Treatment-related side effects, such as certain medications or chemotherapy, can also contribute to hyperkalemia by altering potassium levels in the body1.

Hyperkalemia can lead to life-threatening cardiac conduction disturbances2.

Therefore, it is important for the nurse to determine the apical pulse rate and rhythm.

Choice A is not correct because comparing muscle strength bilaterally is not the most important intervention for a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L).

Choice C is not correct because measuring color and amount of urine is not the most important intervention for a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L).

Choice D is not correct because assessing strength of deep tendon reflexes is not the most important intervention for a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L).

A. Tap the feet forwards and backwards. B. Bend the arm by flexing the ulna to the humerus. C. Turn the head to the right and left. D. Extend the arm at the side and rotate in circles.

Correct Answer is B

Explanation

To exercise the hinge joints, the nurse should instruct the client to bend the arm by flexing the ulna to the humerus.

Hinge joints allow for movement in one direction, like a door hinge. The elbow joint is an example of a hinge joint.

Choice A is not the answer because tapping the feet forwards and backwards exercises the ankle joint, which is not a hinge joint.

Choice C is not the answer because turning the head to the right and left exercises the pivot joint in the neck, which is not a hinge joint.

Choice D is not the answer because extending the arm at the side and rotating in circles exercises the ball-and-socket joint in the shoulder, which is not a hinge joint.

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Which descriptions of stool warrant additional follow-up by the nurse? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When using a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

Correct Answer is B

Explanation

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

Correct Answer is B

Explanation

The nurse observes the skin over a client's greater trochanter, as seen in the picture with pressure sores. What actions should the nurse implement?

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The healthcare provider prescribes ear drops to an adult client with an ear infection. Which exacting should the nurse follow?

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An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert and requests that no heroic measures be implemented if her breathing stops. What actions should the nurse take first?

Which descriptions of stool warrant additional follow-up by the nurse? (Select all that apply.).