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
Explanation
A. Applying lidocaine gel to the urethra may provide additional lubrication but does not address the immediate issue of resistance during catheter insertion.
B. Inflating the catheter's balloon is inappropriate at this stage, as the catheter is not properly positioned for urine flow, and doing so could cause injury.
C. Lowering the penis to a 45° angle helps to straighten the urethra and can facilitate easier passage of the catheter, making it the most appropriate action.
D. Twisting the catheter gently is not recommended, as this may cause trauma to the urethra or increase discomfort without resolving the resistance issue.
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.
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