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A nurse is caring for a client in a long-term care facility.

Exhibits
Which of the following assessment findings require follow-up by the nurse? Select all that apply.

Vocal quality

Blood pressure

Albumin

BMI

Dentition

Bowel pattern

Lung sounds

Temperature

Secretions

Posture

Answer and Explanation

Correct Answer : A,D,F,G,H,I,J

A. Vocal quality – The client’s voice is hoarse and weak on Day 30, which may indicate dehydration, malnutrition, or an underlying respiratory issue.

B. Blood pressure – The client's blood pressure has slightly decreased but remains within a normal range, so it does not require immediate follow-up.

C. Albumin – Serum albumin levels are still within normal range.

D. BMI – The drop from 20 to 19 suggests unintentional weight loss, which could indicate malnutrition, inadequate intake, or an underlying illness.

E. Dentition –No difficulty in chewing reported.

F. Bowel pattern – The client has constipation for three days, which may require intervention to prevent complications like fecal impaction or discomfort.

G. Lung sounds – Diminished breath sounds at the bases may indicate fluid accumulation, atelectasis, or respiratory infection, requiring further evaluation.

H. Temperature – The client’s fever (38.1°C/100.6°F) suggests a possible infection and requires monitoring for underlying illness.

I. Secretions – Thick oral secretions may indicate dehydration, poor oral hygiene, or a swallowing issue, requiring follow-up to prevent aspiration.

J. Posture – The client’s slumped posture and fatigue could indicate weakness, nutritional deficiencies, or an underlying neurological or musculoskeletal problem.

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Correct Answer is A

Explanation

A. Nausea: Nausea is a sign of intolerance to enteral feedings and may indicate delayed gastric emptying or feeding that is too rapid. The nurse should slow the rate of feeding, assess for abdominal distention, and check for residual volume.

B. Urine output 40 mL/hr: Urine output of 40 mL/hr is within the normal range (≥30 mL/hr) and does not indicate intolerance to enteral feedings. However, a significant decrease in urine output (oliguria) could indicate dehydration or kidney issues.

C. Soft stools: Soft stools can be a normal response to enteral feedings unless the client develops diarrhea. Watery, frequent stools may indicate malabsorption, but soft stools alone are not a sign of feeding intolerance.

D. Headache: Headaches are not a common symptom of enteral feeding intolerance. They may be related to other issues such as dehydration, hypertension, or medication side effects.

A. HCTZ 25mg QD B. QOD C. .1 mg D. > 180 systolic E. Amlodipine

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

Explanation

When analyzing cues, the nurse should identify HCTZ, QD, QOD .1 mg, and >180mg systolic as error-prone abbreviations. Medications names, such as hydrochlorothiazide, should be spelled out. QD should be written as daily and QOD should be written as every other day. Decimal points should be written using a leading zero and greater than and less than should be written out rather than using symbols.

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A nurse is caring for a client in a long-term care facility. Exhibits Which of the following assessment findings require follow-up by the nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who has been receiving intermittent enteral feedings which of the following findings should the nurse identify as an indication of intolerance to the feeding?

Correct Answer is A

Explanation

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

Explanation

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A nurse is caring for a client in a long-term care facility.

Exhibits
Which of the following assessment findings require follow-up by the nurse? Select all that apply.