Which of the following findings indicate a potential complication that requires immediate follow-up? (Select All that Apply.)

Neurological assessment

Basic metabolic panel

Blood pressure/heart rate

Abdominal assessment

Complete blood count

Pain assessment

Answer and Explanation

Correct Answer : A,B,C,E,F

A. Neurological assessment is critical in identifying potential complications, especially in cases of head injury, infection, or brain-related conditions. A change in mental status or neurological findings (e.g., confusion, loss of consciousness) warrants immediate follow-up.

B. Basic metabolic panel provides key information on electrolyte imbalances, kidney function, and acid-base status. Imbalances or abnormalities, such as hyperkalemia or hyponatremia, can indicate life-threatening conditions.

C. Blood pressure/heart rate is crucial to monitor because abnormalities in these vital signs can indicate cardiovascular instability, shock, or autonomic dysfunction. Significant changes require immediate intervention.

D. Abdominal assessment is important but not always immediately urgent unless signs of acute abdominal issues (e.g., severe pain, distention, or bleeding) are present.

E. Complete blood count is essential for monitoring for signs of infection, anemia, or bleeding disorders. Abnormalities such as low hemoglobin or a high white blood cell count require further investigation.

F. Pain assessment is important but may not always indicate an immediate life-threatening issue. However, uncontrolled pain or new-onset severe pain can signal a complication, such as infection or tissue damage, which needs prompt attention.

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Correct Answer is ["1"]

Explanation

Total daily dose: 1.5 mg

Divided into 3 equal doses: 1.5 mg / 3 = 0.5 mg per dose

Now, we can calculate the number of tablets:

Number of tablets = Desired dose (mg) / Tablet strength (mg/tablet)

Number of tablets = 0.5 mg / 0.5 mg/tablet = 1 tablet

A. Place the client on his side. B. Hold the client's arms and legs from moving. C. Place the client back in bed. D. Insert a tongue blade in the client's mouth.

Correct Answer is A

Explanation

A. Placing the client on their side is the correct action to prevent aspiration and help keep the airway open during a seizure. It also helps drain secretions and can reduce the risk of choking.

B. Holding the client's arms and legs is not recommended during a seizure because this can lead to injury to the client and the nurse. Seizure activity should be allowed to run its course in a safe environment.

C. Placing the client back in bed during a seizure could be dangerous, as it is better to keep the client safe on the floor to prevent falling or injury. The priority is ensuring the client’s safety during the seizure rather than moving them back into bed.

D. Inserting a tongue blade in the client's mouth is an outdated practice and can lead to injury or even cause the client to bite down on the tongue blade. There is no need to insert anything into the mouth during a seizure.

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Which of the following findings indicate a potential complication that requires immediate follow-up? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["1"]

Explanation

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

At what age is it generally recommended to perform palatoplasty for a child with a cleft palate?

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A nurse is assessing a child who has a suspected head injury. What would be the initial action the nurse should take to assess the child's cognitive status?

When performing the tape test to check for pinworms, when should the caregiver remove the tape from the child's anus?

When administering oral iron supplements to a client with anemia, which nursing action is most important to ensure optimal absorption of the medication?