A nurse is caring for a patient who has cirrhosis of the liver.
The patient’s vital signs are as follows: Heart rate 101/min, Temperature 36 C (96.9 F), Respiratory rate 24/min, Blood pressure 82/58 mm Hg, Oxygen saturation 92%. Which of the following assessment findings require immediate follow-up? Select all that apply.

Abdominal girth.

Blood pressure.

Heart rate.

Oxygen saturation.

Answer and Explanation

Correct Answer : B,C,D

Choice A rationale

While monitoring abdominal girth can be important in patients with cirrhosis, especially those with ascites, it is not typically an assessment finding that requires immediate follow-up.

Choice B rationale

A blood pressure of 82/58 mm Hg is low and could indicate hypotension, which requires immediate follow-up.

Choice C rationale

A heart rate of 101/min is elevated and could indicate tachycardia, which requires immediate follow-up.

Choice D rationale

An oxygen saturation of 92% is lower than the normal range of 95% to 100%, indicating potential hypoxia, which requires immediate follow-up.

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Free Nursing Study Resources

Correct Answer is B,D,E,C,A

Explanation

The correct order of Erikson’s stages of psychosocial development from birth to adolescence is:

Trust vs. mistrust
Autonomy vs. shame and doubt
Initiative vs. guilt
Industry vs. inferiority
Identity vs. role confusion

A. Serve foods that have a hot/cold balance. B. Remove tea and coffee from meal trays. C. Serve milk products separately from meals. D. Request a meal tray without pork.

Correct Answer is D

Explanation

When caring for a patient who practices Islam, the nurse should request a meal tray without pork. Dietary laws in Islam, known as halal, prohibit the consumption of pork.

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Naxlex Comprehensive Predictor Exams

A nurse has accepted a position on a pediatric unit and is learning about psychosocial development. Arrange Erikson’s stages of psychosocial development in order from birth to adolescence.

Correct Answer is B,D,E,C,A

Explanation

A nurse is developing a plan of care for a patient who practices Islam. Which of the following actions should the nurse include in the plan?

Correct Answer is D

Explanation

A nurse is admitting an elderly patient suspected of having a cognitive disorder. What inventories should be included as part of the admission assessment?

A nurse in the emergency department is caring for a patient who reports severe abdominal pain in the left quadrant. The healthcare provider suspects a ruptured ectopic pregnancy.What sign should the nurse look for that indicates the patient has blood in the peritoneum?

A nurse is providing discharge instructions about clean intermittent self-catheterization to a patient who has benign prostatic hyperplasia. Which of the following instructions should the nurse include?

A nurse is caring for a patient suspected of having compromised blood flow to a limb. What factors contribute to poor circulation to the limb?

A nurse is educating a patient who has acute kidney injury about the oliguric phase. What information should the nurse include in the teaching?

A nurse is evaluating a patient who is suffering from prostatic hypertrophy.What symptoms associated with urinary retention should the nurse anticipate? (Choose all that apply)

A nurse is analyzing the lab results of a patient with liver failure and ascites who is on spironolactone. What lab findings should the nurse anticipate?