Exhibits

Identify the findings at 1100, that require follow-up. Select all that apply.

T38.6° C (101.5° F), oral

Apical HR 108/min

BP 112/54 mm Hg, supine

R 22/min

Pulse oximetry 90% on 40% O2 via face mask

Mucous membranes pink.

Answer and Explanation

Correct Answer : A,B,C

A. T 38.6° C (101.5°F), oral. The client’s temperature has increased, which may indicate that the infection is progressing despite treatment. Persistent fever can contribute to dehydration, increased metabolic demand, and worsening systemic inflammation, all of which require further assessment and potential intervention.

B. Apical HR 108/min. The client’s heart rate has risen from 99/min to 108/min, which may be a compensatory response to fever, infection, or early signs of sepsis. Tachycardia combined with hypotension warrants close monitoring for worsening hemodynamic instability.

C. BP 112/54 mm Hg, supine. The blood pressure has decreased from 114/56 mm Hg to 112/54 mm Hg. While this is still within an acceptable range for some clients, the low diastolic pressure may indicate vasodilation due to sepsis or dehydration. If this trend continues or the client becomes symptomatic (e.g., dizziness, altered mental status), further intervention may be needed.

D. R 22/min. The respiratory rate has decreased from 32/min to 22/min, indicating improved respiratory status with oxygen therapy. This does not require follow-up as it falls within the normal range (12-20/min) and suggests a positive response to treatment.

E. Pulse oximetry 95% on 40% O₂ via face mask. The oxygen saturation has improved significantly from 85% on room air to 95% on supplemental oxygen. This suggests that oxygen therapy is effective, and no immediate follow-up is needed for this parameter.

F. Mucous membranes pink. The improvement from pale to pink mucous membranes indicates better oxygenation and perfusion, likely due to supplemental oxygen and improved respiratory function. This is a positive finding that does not require further intervention.

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Correct Answer is A

Explanation

A. Managing knowledge. Nursing informatics involves using information technology to collect, store, analyze, and share knowledge to enhance patient care, improve decision-making, and streamline healthcare processes. This aligns with the primary function of informatics in healthcare.

B. Producing clinical pathways. While informatics can support the development of clinical pathways by analyzing data and trends, its primary purpose is broader—focusing on knowledge management and improving healthcare efficiency rather than just pathway development.

C. Providing a safe place to provide care. Informatics contributes to safety through tools such as electronic health records (EHRs) and clinical decision support systems, but it does not directly create a physical safe space for patient care.

D. Preventing burnout. Informatics can help reduce workload and streamline documentation, potentially lowering stress levels for healthcare providers. However, its main function is to manage knowledge and improve patient care through the use of technology.

A. Demographic data B. Billing payments C. Driver's license D. Facility policies

Correct Answer is A

Explanation

A. Demographic data. An electronic health record (EHR) includes demographic information such as the client’s name, date of birth, contact details, and medical history. This data helps healthcare providers personalize care and ensure accurate record-keeping.

B. Billing payments. While healthcare facilities may have electronic billing systems, financial transactions and payments are not considered a core component of the EHR, which primarily focuses on clinical documentation and patient care.

C. Driver's license. A driver's license may be used for identity verification during registration, but it is not a required component of an EHR. Identifying information is documented separately from clinical records.

D. Facility policies. EHRs store patient-related health information rather than institutional policies. Facility policies are typically maintained in administrative systems or policy manuals, separate from patient medical records.

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Exhibits Identify the findings at 1100, that require follow-up. Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing informatics with a newly licensed nurse. The nurse identifies that informatics is defined as the use of information and technology for which of the following?

Correct Answer is A

Explanation

A charge nurse is providing an in-service on documentation with a group of staff nurses. Which of the following should the nurse include as a component of an electronic health record?

Correct Answer is A

Explanation

A nurse is answering questions at a school meeting about government entities that regulate health care. The nurse should include that which of the following organizations advocates for the delivery of culturally competent health care?

A nurse is caring for four clients who are all requesting assistance. Which of the following clients should the nurse assist first?

A nurse checks a client to evaluate the effectiveness of a pain medication. Which of the following components of professionalism is the nurse demonstrating?

A charge nurse is providing teaching to a newly licensed nurse on the advantages of electronic documentation. Which of the following information should the nurse include in the teaching?

A nurse is designing a poster presentation for staff nurses about therapeutic communication. Which of the following techniques should the nurse include?

A nurse administers the wrong medication to a client. After assessing the client, the nurse contacts the provider and completes an incident report. Which of the following components of professionalism is the nurse demonstrating?

A nurse is teaching a class about the steps of the inflammatory response. The nurse should include that which of the following is the first step in the inflammatory response?

A nurse is assessing a client who reports acute pain at a level of 7 on a scale of 0 to 10. Which of the following findings should the nurse expect?

Exhibits

Identify the findings at 1100, that require follow-up. Select all that apply.