A nurse is caring for a client.

Vital Signs.

1600: Nurses' Notes.

Temperature 37.6°C (99.7°F). Blood pressure 110/58 mm Hg. Heart rate 72/min.

Respiratory rate 18/min.

Pulse oximetry 98% on room air.

1630: Temperature 37.5°C (99.5°F). Blood pressure 78/52 mm Hg. Heart rate 112/min.

Respiratory rate 26/min.

Pulse oximetry 92% on room air.

1600: Antibiotic administered as prescribed.

Bilateral breath sounds clear and present throughout.

1630: Client reports itching on the chest and has urticaria over the chest and trunk.

Client states they are having difficulty swallowing and feel as if there is a lump in their throat.

Bilateral breath sounds with scattered wheezing heard throughout.

Vital Signs.

Nurses' Notes.

Medication Administration Record.

Cefaclor 500 mg PO q8h.

Select the 3 findings that require immediate follow-up.

Breath sounds at 1600.

Temperature.

Urticaria.

Blood pressure at 1630.

Report of dysphagia.

Answer and Explanation

Correct Answer : C,D,E

The correct answer is to select the following three findings that require immediate follow-up: C. Urticaria, D. Blood pressure at 1630, and E. Report of dysphagia.

Choice A rationale:

“Breath sounds at 1600.” The breath sounds at 1600 were clear and present throughout, which is a normal finding and does not require immediate follow-up.

Choice B rationale:

“Temperature.” The temperature readings at both 1600 and 1630 are slightly elevated but not critically high. This does not require immediate follow-up compared to the other findings.

Choice C rationale:

“Urticaria.” The presence of urticaria (hives) indicates an allergic reaction, which can potentially escalate to a more severe reaction such as anaphylaxis. Immediate follow-up is necessary to prevent further complications.

Choice D rationale:

“Blood pressure at 1630.” The blood pressure at 1630 is significantly lower (78/52 mm Hg) compared to the earlier reading (110/58 mm Hg). This hypotension could indicate a serious reaction to the medication or another underlying issue that requires prompt attention.

Choice E rationale:

“Report of dysphagia.” The client’s report of difficulty swallowing and feeling a lump in their throat is concerning for a potential airway obstruction or severe allergic reaction, such as anaphylaxis. This symptom requires immediate follow-up to ensure the client’s airway remains open and to provide necessary interventions.

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Free Nursing Study Resources

Correct Answer is ["4"]

Explanation

To calculate the correct dose in milliliters (mL), you can use the formula: Desired Dose (in mg) = Available Dose (in mg/mL) * Volume (in mL)

Desired Dose (in mg) = 40 mg Available Dose (in mg/mL) = 10 mg/1 mL Now, plug these values into the formula: Volume (in mL) = 40 mg / 10 mg/1 mL Volume (in mL) = 4 mL.

The nurse should administer 4 mL of furosemide per dose.

A. "The use of social media is not included in the COE.”. B. "Professional expectations are included in the COE.”. C. "Student nurses are not held accountable to COE.”. D. "Criteria for obtaining licensure is included in the COE.”. .

Correct Answer is B

Explanation

Choice A rationale:

"The use of social media is not included in the COE.”. This statement is not accurate. The use of social media is addressed in the Code of Ethics (COE) for nurses. The COE provides guidance on how nurses should maintain professional boundaries and ethical behavior in the digital age, which includes considerations for social media use.

Choice B rationale:

"Professional expectations are included in the COE.”. This statement is correct. The Code of Ethics (COE) for nurses outlines the professional expectations and standards that nurses are expected to adhere to. It provides guidance on ethical conduct, accountability, and the responsibilities of nurses in their practice.

Choice C rationale:

"Student nurses are not held accountable to COE.”. This statement is not accurate. Student nurses are expected to adhere to the same ethical standards outlined in the Code of Ethics (COE) as registered nurses. While there may be some variations in practice expectations based on the level of training, ethical principles apply to all nurses, including student nurses.

Choice D rationale:

"Criteria for obtaining licensure is included in the COE.”. This statement is not accurate. The Code of Ethics (COE) primarily focuses on ethical principles, professional behavior, and the responsibilities of nurses in their practice. It does not typically include criteria for obtaining licensure, as licensure requirements are determined by licensing boards and regulatory bodies.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer furosemide 40 mg IV. Available is furosemide 10 mg/1 mL. How many mL should the nurse administer per dose?

Correct Answer is ["4"]

Explanation

A nurse is preparing an in-service to review the Code of Ethics (COE) with a group of nursing colleagues.Which of the following statements should the nurse make during the in-service about the COE?

Correct Answer is B

Explanation

A nurse is preparing to provide discharge teaching for an adolescent who has a cognitive disorder and their parents.Which of the following actions should the nurse take?

A nurse is teaching a newly licensed nurse about end-of-life care.The nurse should include that which of the following services provides support for a client's caregiver?

A nurse is caring for a client who is desiring their wound care to be provided at 1400.The nurse returns at 1400 to perform wound care for the client.Which of the following ethical principles is the nurse demonstrating?

A nurse is preparing to review discharge instructions with a client who reports having hearing loss.Which of the following actions should the nurse plan to take?

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

A nurse is gathering evidence-based practice on catheter-associated urinary tract infections (CAUTI). Which of the following roles is the nurse performing?

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