Try Naxlex NCLEX-RN (Free-Trial)

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Numerical pain scale. Clients with dementia often have difficulty understanding and using numerical pain scales.

B. Verbal description. Many clients with dementia have impaired verbal communication, making it difficult to describe pain effectively.

C. FACES pain scale. While this scale is useful for some nonverbal populations, it still requires the client to actively choose a face, which may be difficult for those with advanced dementia.

D. Behavioral indicators. Observing facial expressions, body movements, vocalizations, and changes in vital signs can help assess pain in clients who cannot self-report. The PAINAD (Pain Assessment in Advanced Dementia) scale is commonly used.

A. Attach a probe carefully to the client's finger to prevent discomfort. B. Apply a sensor pad to the client's forehead. C. Secure a probe to one of the client's toes. D. Obtain a pulse oximetry reading when peripheral edema has decreased.

Correct Answer is B

Explanation

A. Attach a probe carefully to the client's finger to prevent discomfort. Peripheral edema may impair circulation, leading to inaccurate readings.

B. Apply a sensor pad to the client's forehead. The forehead provides a more accurate reading when peripheral circulation is compromised.

C. Secure a probe to one of the client's toes. Thickened toenails and edema may interfere with an accurate reading.

D. Obtain a pulse oximetry reading when peripheral edema has decreased. The nurse should not delay obtaining an oxygen saturation reading if an alternative site is available.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 assessing the pain level of a client who has dementia and difficulty communicating. Which of the following pain assessment techniques should the nurse use?

Correct Answer is D

Explanation

A nurse is preparing to obtain the oxygen saturation of a client who has peripheral edema and thickened toenails. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who has an Indwelling urinary catheter. Which of the following findings should the nurse Identify as an indication of a possible catheter occlusion?

A nurse is planning to administer several medications to a client through a nasogastric (NG) tube. Which of the following actions should the nurse take?

A nurse is teaching a client about the correct use of a cane. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

A nurse is caring for a client who has dementia and frequently tries to get out of bed. Which of the following actions should the nurse take? (Select all that apply.)

A charge nurse is preparing a teaching session for a group of newly licensed nurses about the general principles of Immunity. Which of the following statements should the nurse plan to include in the teaching?

A nurse receives a report from an assistive personnel that a client's blood pressure is 160/95 mm Hg. Which of the following actions should the nurse take first?

A nurse is caring for a client in the emergency department. Exhibits Complete the following sentence by using the lists of options. To implement the provider's prescriptions the nurse should dropdown because this will dropdown

A nurse in a provider's office is assessing the motor skill development of a 15-month-old toddler during a well-child visit. Which of the following gross motor skills should the nurse expect?

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.