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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Decreased peripheral pulses. Fever leads to vasodilation and increased cardiac output, which generally enhances peripheral blood flow. As a result, peripheral pulses are more likely to be strong and bounding rather than decreased.

B. Dilated pupils. Pupil dilation is associated with sympathetic nervous system activation, often due to stress, fear, or certain medications. Fever alone does not typically cause pupil dilation, making this an unlikely expected finding.

C. Respiratory rate 10/min. Fever usually increases metabolic demand, leading to a higher respiratory rate (tachypnea) rather than a lower one. A respiratory rate of 10 breaths per minute would be considered bradypnea, which is not a typical response to fever.

D. Heart rate 108/min. Fever stimulates the sympathetic nervous system, increasing heart rate (tachycardia) to meet the body’s higher metabolic and oxygen demands. A heart rate of 108/min is expected in response to a fever of 39°C (102.2°F).

A. Respiratory therapist B. Social worker C. Dietician D. Occupational therapist

Correct Answer is B

Explanation

A. Respiratory therapist. A respiratory therapist provides care related to breathing disorders, such as managing oxygen therapy or ventilators. They are not typically involved in coordinating home health services for wound care.

B. Social worker. A social worker assists with coordinating home health services, arranging follow-up care, and addressing financial or logistical barriers to receiving treatment at home. They ensure the client has access to necessary resources, including wound care services.

C. Dietitian. A dietitian helps with nutritional planning to support wound healing, such as recommending a high-protein diet. While nutrition is important in recovery, a dietitian does not arrange home health care services.

D. Occupational therapist. An occupational therapist helps clients regain the ability to perform daily activities after illness or injury. While they may assist in recovery, they do not arrange wound care services for home health needs.

View Question and Answer

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

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has an oral temperature of 39° C (102.2° F). Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is performing discharge teaching with a client who has a wound that requires home health care. Which of the following team members should the nurse contact for consultation?

Correct Answer is B

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?

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 providing a presentation to a group of nurses on lifelong learning in nursing. Which of the following resources should the nurse include in the teaching? Select all that apply.

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

A nurse is planning a presentation on health promotion activities for clients who have hypertension. Which of the following should the nurse utilize as a resource for this information?

A nurse is updating the Minimum Data Set (MDS) forms for the residents of a long-term care facility. A nursing colleague asks about the significance of MDS documentation. Which of the following statements should the nurse make?

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.

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?

Exhibits

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