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. Nurses might focus on a client's physiological needs over psychosocial needs when communicating during care. When a client is experiencing a critical health issue, nurses often prioritize physiological concerns, such as pain management and vital signs, over psychosocial aspects. While emotional support is important, immediate medical needs take precedence in acute situations.

B. Nurses caring for clients experiencing a highly emotional situation report that communication is rarely affected. High emotional distress can significantly impact communication between the nurse and client. Clients in crisis may struggle to process information, while nurses might need to adjust their communication style to provide reassurance and clarity.

C. Clients who have developmental deficits are less distracted by environmental noises than clients that do not have these deficits. Clients with developmental deficits, such as cognitive impairments, may actually be more affected by environmental noise. Distractions can further hinder their ability to focus and communicate effectively.

D. Hearing loss is considered a developmental factor that has minimal effect on nurse-client communication. Hearing loss has a significant impact on communication, requiring nurses to use strategies like speaking clearly, using written materials, or employing assistive devices to ensure effective interaction.

A. The client will explain 4 principles of crutch safety. B. The client will teach back information about safe crutch walking on day 1. C. The client will walk 10 feet by day 2. D. The client will demonstrate safe crutch walking. E. The client will walk 20 feet by day 3. F. The client will not lean on the crutches to support their body weight. G. The client will explain how to keep crutches in working condition. H. The client will ambulate 5 feet in one day.

Correct Answer is ["B","C","E","H"]

Explanation

A. The client will explain 4 principles of crutch safety. This statement lacks a specific time frame, making it not a timed component of SMART goals.

B. The client will teach back information about safe crutch walking on day 1. The goal includes a clear time frame (day 1), making it a timed component that aligns with SMART criteria.

C. The client will walk 10 feet by day 2. This goal includes a specific distance and deadline (day 2), making it measurable and time-bound.

D. The client will demonstrate safe crutch walking. While this is an important skill, the statement does not specify a time frame, meaning it does not meet the timed component of SMART goals.

E. The client will walk 20 feet by day 3. This statement sets a clear distance goal with a deadline (day 3), making it a timed SMART goal.

F. The client will not lean on the crutches to support their body weight. While this is an important behavior, it lacks a time frame, meaning it is not a timed component.

G. The client will explain how to keep crutches in working condition. This statement is a general goal without a deadline, making it not a timed SMART goal.

H. The client will ambulate 5 feet in one day. This goal provides a specific distance and deadline (one day), making it a timed component of the SMART criteria.

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

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Naxlex Comprehensive Predictor Exams

A nurse is discussing factors that influence communication with a group of newly licensed nurses. Which of the following information should the nurse include?

Correct Answer is A

Explanation

A nurse is writing a teaching plan using the Specific, Measurable, Attainable, Relevant, and Timed Outcome (SMART) goals for a client who is learning to walk with crutches. Which of the following are timed components of the SMART outcome goals? Select all that apply.

Correct Answer is ["B","C","E","H"]

Explanation

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A nurse is providing an in-service to a group of newly licensed nurses on standards of practice and the role of the Board of Nursing (BON). Which of the following information should the nurse include?

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

Exhibits

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