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Exhibits

Select the 3 findings that require immediate follow-up by the nurse.

Mucus membranes

Integumentary findings

Emesis

Behavior

AST result

Vital signs

Movement of hands and fingers

Answer and Explanation

Correct Answer : B,D,F

A. Mucous membranes: Although they are noted to be dry, this alone is not an urgent finding. Mild dehydration may be monitored, especially when the client is stable and has IV access established.
B. Integumentary findings: Scratch marks and intense pruritus are consistent with cholestasis from liver dysfunction. This can lead to excoriation, infection, or indicate worsening hepatic failure, especially in the context of jaundice and elevated bilirubin.
C. Emesis: No vomiting or emesis is mentioned anywhere in the case details, making this an irrelevant and unsupported option for follow-up.
D. Behavior: The client is disoriented to time and displaying agitation with inappropriate language. In a client with alcohol use disorder and cirrhosis, this behavior can indicate the onset of hepatic encephalopathy which can rapidly progress and require immediate attention.
E. AST result: The AST level is significantly elevated (208 units/L), but liver enzymes are not immediate threats requiring urgent action. They confirm liver injury but do not direct acute intervention.
F. Vital signs: The client has a significantly elevated blood pressure (188/94 mmHg), tachycardia (120/min), and an increased temperature (38.4°C). These may reflect an acute withdrawal syndrome, sepsis, or intracranial injury—all of which demand urgent follow-up.
G. Movement of hands and fingers: There is no indication of tremors, asterixis, or motor deficits in the notes. Therefore, hand and finger movement does not currently present as a priority concern.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. "You may experience a decrease in your blood pressure while taking this medication.": Orthostatic hypotension is a possible side effect, but it's not as common or specific as sedation-related concerns for this medication.
B. "You may experience weight loss while taking this medication.": Doxepin, a tricyclic antidepressant, is more commonly associated with weight gain due to increased appetite, not weight loss.
C. "You may experience diarrhea while taking this medication.": Doxepin is more likely to cause constipation rather than diarrhea due to its anticholinergic effects.
D. "You may experience insomnia if you take this medication later in the day.": Doxepin has sedative properties. Taking it late in the day can disrupt the natural sleep-wake cycle, paradoxically leading to sleep disturbances or difficulty initiating restful sleep.

A. Insert an indwelling urinary catheter. B. Administer an IV diuretic. C. Initiate oxygen via face mask. D. Request an analysis of ABGs.

Correct Answer is C

Explanation

A. Insert an indwelling urinary catheter: This may be necessary to monitor fluid output after diuretic therapy, but it is not the immediate priority when oxygenation is compromised due to fluid in the lungs.
B. Administer an IV diuretic: Diuretics help reduce fluid overload, which is key in managing pulmonary edema, but oxygenation must be addressed first to stabilize the client and prevent hypoxia.
C. Initiate oxygen via face mask: The most urgent concern in acute pulmonary edema is impaired gas exchange. Administering oxygen immediately helps improve oxygenation and is the priority intervention to address life-threatening hypoxia.
D. Request an analysis of ABGs: While ABG results are important to assess respiratory function and guide further treatment, drawing labs takes time. Oxygen administration should not be delayed in order to obtain lab values.

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Exhibits Select the 3 findings that require immediate follow-up by the nurse.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has a new prescription for doxepin. Which of the following instructions should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is caring for a client who has acute pulmonary edema. Which of the following is the priority nursing intervention?

Correct Answer is C

Explanation

A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse plan to take?

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Exhibits

Select the 3 findings that require immediate follow-up by the nurse.