36. A nurse is caring for a client.
Exhibits
Which of the following findings at 1015 requires further action?

(Select all that apply.)

Low back pain

Urine color

Blood pressure

Respiratory rate

Answer and Explanation

Correct Answer : C,D

A.   While low back pain can be concerning, it's not an immediate priority compared to the vital sign changes. However, the nurse should document the pain and ask about its characteristics.
B.   Brown-colored urine can sometimes indicate dehydration or certain medical conditions, requiring follow-up.
C.   A significant drop in blood pressure (74/50 mmHg) indicates hypotension and requires immediate attention.
D.   An increase in respiratory rate (28 breaths/min) suggests the client may be experiencing respiratory distress and needs evaluation.
E.   The client’s oxygen saturation is 95% on room air which is normal.

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Correct Answer is C

Explanation

A. Tremor is not a common adverse effect of atenolol.
B. Constipation is not typically associated with atenolol.
C. Bradycardia (slow heart rate) is a known adverse effect of atenolol, a beta-blocker that can decrease heart rate and blood pressure.
D. Cough is more commonly associated with ACE inhibitors, not beta-blockers like atenolol.

A. Positive Western blot test B. Platelets 150,000/mm3 C. CD4-T-cell count 180 cells/mm3 D. WBC 5,000/mm3

Correct Answer is C

Explanation

A. A positive Western blot test confirms HIV infection but does not provide immediate information on the client's immune status.
B. Platelets within the normal range are important but do not directly indicate the client's immune status or HIV progression.
C. CD4-T-cell count is crucial for monitoring HIV progression and immune function. A low count indicates immunosuppression and increased risk of opportunistic infections.
D. WBC count is important but does not specifically indicate the client's HIV status or immune function related to HIV.

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36. A nurse is caring for a client. Exhibits Which of the following findings at 1015 requires further action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has hypertension and a new prescription for atenolol. Which of the following findings should the nurse include as adverse effects of this medication?

Correct Answer is C

Explanation

A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?

Correct Answer is C

Explanation

A nurse is planning care for a client who is receiving enteral feedings through an NG tube. Which of the following actions should the nurse plan to take first?

A nurse is administering morphine 2 mg IV every 2 to 4 hr to a client who has an abdominal incision. The nurse should monitor the client for which of the following adverse effects?

A nurse is assessing a client's ability to ambulate with crutches using a three-point gait. Which of the following actions should the nurse identify as a risk to the client's safety?

A nurse plans to leave her scheduled shift an hour early without permission or notification of the charge nurse. The clients in the nurse's assignment are stable. Which of the following legal torts applies to this situation?

A nurse is caring for a client whose serum potassium level is 5.3 mEq/L. Which of the following scheduled medications should the nurse plan to administer?

A nurse is preparing to administer 10 units of regular insulin and 20 units of NPH insulin to a client who has diabetes mellitus. When mixing the two types of insulin, which of the following actions should the nurse take first?

Exhibits The nurse inspects the airway. There is no visible trauma, and the airway appears to be patent. What other assessment items are included in the primary survey? Select all that apply.

A nurse is caring for a client who is hospitalized with active pulmonary tuberculosis and is started on ethambutol therapy. The nurse should understand that which of the following should be monitored?

36. A nurse is caring for a client.
Exhibits
Which of the following findings at 1015 requires further action?