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A nurse is assisting in the care of an adolescent.

The nurse is reviewing the data collection findings.

Select the 5 findings the nurse should report to the provider.

Temperature

Sclera

Bowel sounds

Abdominal tenderness

Anorexia

Breath sounds

Heart rate

Skin

Answer and Explanation

Correct Answer : B,D,E,G,H

Temperature: A temperature of 37.5° C (99.5° F) is within the normal to slightly elevated range and is not high enough to be classified as fever. Therefore, it does not require immediate reporting unless accompanied by other signs of infection or systemic illness.
Sclera: Yellow-tinged sclera suggests jaundice, indicating possible liver dysfunction, which could be related to substance use or hepatitis. Jaundice is a significant clinical finding that requires immediate provider notification for further evaluation and management.
Bowel sounds: Hyperactive bowel sounds are a non-specific finding and can result from gastrointestinal irritation, substance use, or stress. Alone, they do not warrant urgent reporting unless accompanied by more serious signs like severe pain or vomiting.
Abdominal tenderness: Epigastric tenderness could suggest gastrointestinal complications such as hepatitis, pancreatitis, or gastritis, especially in the context of drug use. Abdominal pain on palpation is a concerning symptom that must be reported for further diagnostic workup.
Anorexia: Significant anorexia along with nausea, vomiting, and substance use points to potential systemic illness or gastrointestinal involvement. In adolescents, persistent anorexia is a warning sign that needs prompt evaluation to prevent nutritional deficiencies and worsening health.
Breath sounds: Clear breath sounds are a normal finding and do not require immediate provider notification. There are no respiratory concerns indicated by the lung assessment provided in the notes.
Heart rate: A heart rate of 103/min indicates mild tachycardia, which could be due to dehydration, substance use, or an underlying systemic condition. Tachycardia should be reported to assess if immediate interventions like fluid replacement are necessary.
Skin: Dry skin with poor turgor signals dehydration, a critical finding especially with the reported vomiting and drug use. Dehydration can rapidly worsen and must be addressed by the provider for fluid management and further care.

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Free Nursing Study Resources

Correct Answer is ["0.25"]

Explanation

Desired dose = 0.25 mg

Available concentration = 1 mg/mL

Calculate the volume to administer:

Volume to administer (mL) = Desired dose (mg) / Available concentration (mg/mL)

= 0.25 mg / 1 mg/mL

= 0.25 mL

A. Active movement is present B. Pain is 4 on scale of 0 to 10 C. Capillary refit is less than 2 seconds D. Skin is cool to the touch

Correct Answer is D

Explanation

A. Active movement is present: The presence of active movement in the fingers and toes of the affected arm indicates that nerve and muscle function are intact, which is a positive finding. It indicates there is no impairment in function of the affected arm.

B. Pain is 4 on scale of 0 to 10: A pain level of 4 is moderate pain and might be expected after a fracture. As long as pain is being managed appropriately with prescribed medications and no other concerning symptoms are present, it does not necessarily require immediate reporting.

C. Capillary refill is less than 2 seconds: A capillary refill time of less than 2 seconds is normal. This suggests good blood flow to the affected arm and is not an issue that needs reporting.

D. Skin is cool to the touch: A cool skin temperature on the affected arm could indicate impaired circulation, possibly due to swelling or tightness of the cast, which could lead to compartment syndrome—a serious condition that requires immediate intervention. Therefore, this finding should be reported to the provider immediately.

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A nurse is assisting with the care of a client.

Select the 4 responsibilities the nurse has in relation to the client's advance directives.

View Question and Answer

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A nurse is assisting in the care of an adolescent. The nurse is reviewing the data collection findings. Select the 5 findings the nurse should report to the provider.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["0.25"]

Explanation

A nurse is caring for a client who has a fractured arm in a cast. Which of the following findings about the affected arm should the nurse report to the provider?

Correct Answer is D

Explanation

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A nurse is assisting with the care of a client. Select the 4 responsibilities the nurse has in relation to the client's advance directives.

A nurse is assisting in the care of an adolescent.

The nurse is reviewing the data collection findings.

Select the 5 findings the nurse should report to the provider.