A nurse is caring for a client in an emergency department (ED).
Exhibits
Which of the following findings in the client's medical record requires follow-up by the nurse? Select all that apply

Blood pressure

Syncope

ECG

Albumin

Answer and Explanation

Correct Answer : A,B,C,D,E,F

Rationale:

A. Blood pressure: Orthostatic hypotension is evident from the drop in systolic and diastolic pressure when standing, indicating fluid and electrolyte imbalance. This may reflect volume depletion due to purging and requires monitoring to prevent fainting or falls.

B. Syncope: The client reports repeated fainting episodes, a red flag when paired with orthostatic hypotension and electrolyte disturbances. This suggests unstable cardiovascular status and raises the risk of injury or sudden cardiac events.

C. ECG: Sinus tachycardia with premature ventricular contractions indicates cardiac irritability likely due to electrolyte imbalance, especially hypokalemia. Continuous cardiac monitoring and correction of abnormalities are needed.

D. Albumin: An albumin level of 2.6 g/dL indicates significant malnutrition and protein deficiency, compromising immune function and wound healing. This also suggests a chronic issue requiring dietetic intervention and nutritional rehabilitation.

E. Potassium: Potassium at 3.0 mEq/L is dangerously low and a known contributor to cardiac arrhythmias and muscle weakness. Replenishment and close monitoring are critical to avoid complications such as cardiac arrest.

F. Sodium: Although sodium is only slightly low at 134 mEq/L, in the context of purging and poor intake, this could indicate dilutional hyponatremia. It increases seizure risk and needs assessment of fluid status and intake behaviors.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

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

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:

A. Check the label of the medication twice prior to administration: Safe medication practice requires the nurse to check the medication label three times, when retrieving, preparing, and before administering to minimize the risk of medication errors.

B. Use two identifiers to verify the client's identity: Using two patient identifiers, such as name and date of birth, ensures the medication is given to the correct individual. This step is crucial for patient safety and is a core component of safe medication administration practices.

C. Document administration of the client's routine medications at the beginning of the shift: Medications should only be documented after they have been administered. Pre-charting medication administration can lead to errors if the medication is delayed, omitted, or refused.

D. Ensure the medication is administered within 3 hr of the scheduled time: Medications are typically required to be administered within 30 minutes to 1 hour of the scheduled time unless otherwise specified. A 3-hour window is too broad and may compromise therapeutic effectiveness.

A. Collect 4 mL/kg of blood in a 24-hr period. B. Apply lidocaine cream 30 min prior to collecting the specimen. C. Ask the parents to leave the room prior to collecting the blood specimen. D. Demonstrate the use of the equipment to the child.

Correct Answer is D

Explanation

Rationale:

A. Collect 4 mL/kg of blood in a 24-hr period: This volume exceeds safe limits for blood collection in small children. The guideline is not to exceed 3 mL/kg over 24 hours unless clinically necessary, as excessive draws can lead to anemia or hemodynamic instability.

B. Apply lidocaine cream 30 min prior to collecting the specimen: While lidocaine-prilocaine cream can be helpful, it typically requires at least 60 minutes to achieve adequate dermal analgesia. Applying it for only 30 minutes may not be sufficient to reduce pain effectively.

C. Ask the parents to leave the room prior to collecting the blood specimen: Parents are often a source of comfort and reassurance for preschoolers. Unless their presence is disruptive, involving them in the process can help calm the child and improve cooperation.

D. Demonstrate the use of the equipment to the child: Preschoolers benefit from age-appropriate explanations and demonstrations. Showing them the equipment reduces fear and anxiety by promoting familiarity and a sense of control in an unfamiliar situation.

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 an emergency department (ED).Exhibits Which of the following findings in the client's medical record requires follow-up by the nurse? Select all that apply

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer medication to a client. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is preparing to obtain a blood specimen from a preschooler. Which of the following actions should the nurse perform?

Correct Answer is D

Explanation

A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching?

A nursery nurse is attending the birth of a post-term infant Exhibits Fill in each blank in the following sentence. Upon review of the medical record, the nurse should determine the infant newborn is at risk for developing dropdown and dropdown.

A nurse is teaching a client who has herpes zoster. Which of the following statements should the nurse make?

A nurse at a community health clinic is planning care for an adolescent who recently learned that she is pregnant and is concerned about her ability to afford and care for her baby. Which of the following actions should the nurse take?

A nurse is preparing a sterile field for a client who requires a dressing change. Which of the following actions should the nurse plan to take?

A nurse is caring for a client who had a laparoscopic cholecystectomy and is experiencing abdominal distention. Which of the following actions should the nurse take?

A nurse is assessing a client who was placed in restraints for aggressive behavior. The client is now calm and cooperative. Which of the following actions should the nurse take?

A nurse is assisting a client who lives in a rural community with obtaining health services. Which of the following actions by the nurse demonstrates coordination of care?

A nurse is caring for a client in an emergency department (ED).
Exhibits
Which of the following findings in the client's medical record requires follow-up by the nurse? Select all that apply