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Exhibits

Select the 4 assessment findings that require immediate follow up.

Radial and pedal pulses 2+

Vomiting small amounts of green bile

Blood pressure 115/76 mm Hg

Feels anxious

Capillary refill 2 seconds

Heart rate 121 beats/minute

Temperature 100.8° F (38.2° C)

Respirations 28 breaths/minute with shallow breathing

Severe abdominal pain in right lower quadrant

Answer and Explanation

Correct Answer : B,F,G,I

A. Radial and pedal pulses 2+: This is a normal finding indicating adequate peripheral perfusion. It does not require immediate follow-up unless paired with other circulatory deficits.

B. Vomiting small amounts of green bile: Suggests possible bowel obstruction or irritation of the upper GI tract. Bile-stained emesis is abnormal and needs urgent evaluation to rule out obstruction or surgical abdomen.

C. Blood pressure 115/76 mm Hg: This is within normal limits for a young adult and does not indicate hemodynamic instability. No immediate action is needed based on this BP reading.

D. Feels anxious: Anxiety is common in acute illness and not unusual in the emergency setting. It should be addressed supportively but does not indicate an urgent clinical issue requiring intervention.

E. Capillary refill 2 seconds: This is a normal peripheral perfusion finding and does not signal shock or poor circulation. No immediate follow-up is needed for this assessment.

F. Heart rate 121 beats/minute: Indicates tachycardia, which may be a response to pain, fever, or systemic inflammation. This vital sign requires immediate follow-up to determine the underlying cause and prevent worsening.

G. Temperature 100.8° F (38.2° C): Suggests the possibility of infection, especially when combined with right lower quadrant pain. This may be a sign of appendicitis or another intra-abdominal inflammatory process.

H. Respirations 28 breaths/minute with shallow breathing: Tachypnea with shallow effort suggests pain or possible early compensation for systemic distress. This finding warrants further assessment but is less immediately concerning than the others listed.

I. Severe abdominal pain in right lower quadrant: This could indicate appendicitis or another surgical emergency. Sudden onset pain in this region with fever and vomiting requires urgent diagnostic imaging and intervention.

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Correct Answer is ["A","C","D"]

Explanation

A. Institute contact precautions for staff and visitors: MRSA is a highly transmissible organism, especially through contact with wound drainage, so implementing contact precautions is essential to prevent spread.

B. Explain the purpose of a low bacteria diet: A low bacteria (neutropenic) diet is used for immunocompromised clients, such as those with neutropenia or undergoing chemotherapy, but is not appropriate or relevant in the context of a MRSA wound infection.

C. Send wound drainage for culture and sensitivity: Culturing the wound helps identify the exact organism and determine the most effective antibiotic treatment, guiding targeted therapy for MRSA.

D. Monitor the client's white blood cell count: Monitoring WBC count is essential to assess the client’s immune response and track infection progression or resolution in osteomyelitis with suspected MRSA.

E. Use standard precautions and wear a mask: Standard precautions are always necessary, but a mask is not required for MRSA unless there is a risk of droplet transmission (e.g., respiratory MRSA), which is not indicated in this wound-related case.

A. Administer an antiemetic to prevent vomiting. B. Apply bilateral eye shields to reduce photosensitivity. C. Begin postoperative prophylactic antibiotics. D. Report the eye pain to the surgeon.

Correct Answer is D

Explanation

A. Administer an antiemetic to prevent vomiting: Vomiting can increase intraocular pressure, but administering an antiemetic is not the priority when the client reports new acute deep eye pain, which may indicate a serious complication.

B. Apply bilateral eye shields to reduce photosensitivity: Eye shields are helpful for protection postoperatively, but photosensitivity is not the focus here; acute deep eye pain suggests a potentially urgent problem requiring physician evaluation.

C. Begin postoperative prophylactic antibiotics: Antibiotics help prevent infection but do not address the sudden onset of deep eye pain, which could indicate serious issues like increased intraocular pressure or surgical complications.

D. Report the eye pain to the surgeon: Acute, deep eye pain following trabeculoplasty may signal a complication such as acute angle-closure glaucoma or hemorrhage, and immediate surgeon notification is necessary for prompt intervention.

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Exhibits Select the 4 assessment findings that require immediate follow up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with osteomyelitis from a compound fracture of the left tibia has an open draining wound and is admitted with possible methicillin-resistant Staphylococcus aureus (MRSA) infection. Which interventions should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. Which action should the nurse take?

Correct Answer is D

Explanation

An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)

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Exhibits

Select the 4 assessment findings that require immediate follow up.