A nurse is reviewing the medical record of a client.
Click to highlight below the findings that require immediate follow-up.
Body system/Findings
Neurological- Alert and oriented to person, place, and time; deep tendon reflexes 4+
Musculoskeletal - Generalized weakness with equal bilateral muscle strength and mild leg cramping
Respiratory- Lungs clear
Cardiovascular- Heart rate irregular: Heart rate 95/min
Gastrointestinal- Bowel sounds hyperactive x 4 quadrants
Neurological- Alert and oriented to person, place, and time; deep tendon reflexes 4+
Musculoskeletal - Generalized weakness with equal bilateral muscle strength and mild leg cramping
Respiratory- Lungs clear
Cardiovascular- Heart rate irregular: Heart rate 95/min
Gastrointestinal- Bowel sounds hyperactive x 4 quadrants
The Correct Answer is ["D","E"]
Rationale:
A. These neurological findings are within normal limits and do not require immediate follow-up.
B. These musculoskeletal findings are not indicative of an emergency and can be addressed during routine care.
C. Clear lung sounds are a normal finding and do not require immediate follow-up.
D. An irregular heart rate may indicate an arrhythmia or other cardiovascular issue that requires further assessment and intervention.
E. Hyperactive bowel sounds can indicate a variety of gastrointestinal issues, including bowel obstruction or ileus, which may require immediate intervention or further investigation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C,A,B,D,E
Explanation
A. Opening the outside cover of the sterile kit and removing the dust cover exposes the sterile supplies within the kit.
B. Grasping the outermost flap of the sterile kit while opening away from the body helps maintain the sterility of the contents within the kit.
C. Preparing a dry work surface above the waist level ensures that the sterile field is established at a proper height and that the nurse's hands are at the appropriate level for working within the sterile field.
D. Opening the innermost lower flap of the sterile kit while standing away from the sterile field allows the nurse to access the sterile supplies without contaminating the sterile field.
E. Opening each side flap of the sterile kit individually while pulling to the side further establishes the sterile field and provides access to the sterile supplies.
Correct Answer is B
Explanation
Rationale:
A. A BMI of 30 or higher is classified as obese.
B. A BMI between 25 and 29.9 is classified as overweight.
C. A BMI below 18.5 is classified as underweight.
D. A BMI between 18.5 and 24.9 is classified as ideal body weight.
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