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 D

Explanation

A. Klebsiella is typically treated with other antibiotics, such as cephalosporins or carbapenems.
B. Pseudomonas aeruginosa is usually treated with antipseudomonal penicillins or cephalosporins.
C. Candida is a fungal infection treated with antifungals like fluconazole.
D. Vancomycin is particularly effective against methicillin-resistant Staphylococcus aureus (MRSA), making it the preferred treatment for MRSA infections.

A. Adjust the prescribed weights every shift. B. Monitor peripheral pulses in the affected extremity. C. Examine the skin under the traction splint. D. Assess the temperature of the affected extremity. E. Position weights against the foot of the bed.

Correct Answer is ["B","C","D"]

Explanation

A. Traction weights are typically set by the physician and shouldn't be adjusted by the nurse unless specifically ordered.
B. Monitoring peripheral pulses helps assess circulation and neurovascular status in the affected extremity.
C. Examining the skin under the traction splint is essential to assess for skin integrity and prevent complications like pressure ulcers.
D. Assessing the temperature of the affected extremity helps detect signs of circulatory impairment or infection.
E. Positioning weights against the foot of the bed is not a correct action for managing Buck's traction.

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

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Naxlex Comprehensive Predictor Exams

A nurse manager is providing an educational program on antibiotic sensitivity to bacterial infections. The nurse should include in the teaching that vancomycin is indicated for which of the following infections?

Correct Answer is D

Explanation

A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

A nurse is teaching a class on health promotion and illness prevention. The nurse should include that which of the following is an example of secondary prevention?

A nurse is assessing a client to identify risk factors for disease. Which of the following findings is a risk factor for metabolic syndrome?

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A nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease. Which of the following statements by the client should indicate to the nurse the need for further teaching?

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