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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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Correct Answer is D

Explanation

A. The client reports a pain level of 6 on a scale from 0 to 10: Moderate pain is expected after surgery and should be managed, but it is not immediately life-threatening or the highest priority.
B. The client refuses to look at the colostomy: Emotional adjustment is important, but this does not pose an immediate physical risk to the client and can be addressed over time with support and education.
C. The colostomy has had no output: It is common for a new colostomy to have delayed output within the first 24 hours postoperatively, so this finding is expected and not immediately concerning.
D. The stoma appears dark purple in color: A dark purple stoma indicates compromised blood flow or ischemia, which is a medical emergency requiring immediate intervention to prevent tissue necrosis and further complications.

A. Abdominal aortic aneurysm B. Osteoarthritis C. Phlebitis D. Peripheral neuropathy

Correct Answer is D

Explanation

A. Abdominal aortic aneurysm: While this condition is serious, it does not directly affect the safety of applying localized heat therapy to a distal site like the foot, unless systemic complications are present.
B. Osteoarthritis: Heat therapy is often beneficial in osteoarthritis, as it helps reduce joint stiffness and improve circulation to the affected area, making it a common and safe intervention.
C. Phlebitis: Warm compresses are sometimes used in phlebitis to reduce inflammation and promote comfort, provided there are no signs of infection or severe vascular compromise.
D. Peripheral neuropathy: Clients with peripheral neuropathy have impaired sensation and may not feel excessive heat, increasing the risk of burns or tissue injury. This makes heat therapy unsafe for these individuals.

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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 assessing a client who had a colostomy 24 hr ago. Which of the following findings is the nurse's priority?

Correct Answer is D

Explanation

A nurse is reviewing the medical record of a client who has a prescription for intermittent heat therapy for a foot injury. Which of the following findings should the nurse identify as a contraindication for heat therapy?

Correct Answer is D

Explanation

A nurse is caring for a client who is experiencing status epilepticus. Which of the following medications should the nurse expect to administer?

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A nurse is preparing a client for transfer to a long-term rehabilitation facility following a below-the-knee amputation of the right leg. Which of the following actions should the nurse take to protect the client's confidentiality?

Exhibits

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