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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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Encourage progressive active range of motion: Range of motion exercises are important in burn rehabilitation, but they do not directly address the underlying cause of bone pain and muscle weakness one year post-injury.

B. Explain the need for skin exposure to sunlight without sunscreen: While sunlight helps in vitamin D synthesis, advising exposure without sunscreen can increase the risk of skin damage or cancer, particularly in someone with burn scars and sensitive skin.

C. Teach the need for dietary and supplemental vitamin D: Clients with extensive burns are at risk for long-term vitamin D deficiency due to impaired synthesis in damaged skin, leading to bone pain and muscle weakness. Supplementation is essential for bone health and recovery.
D. Instruct the client in the use of muscle strengthening exercises: Muscle strengthening may support recovery, but addressing the vitamin D deficiency causing bone and muscle symptoms is the priority intervention.

A. Complete ongoing focused assessments of a client with wrist restraints. B. Supervise a newly hired graduate nurse during an admission assessment. C. Administer PRN oral analgesics to a client with a history of chronic pain. D. Transport a client who is receiving IV fluids to the radiology department.

Correct Answer is B

Explanation

A. Complete ongoing focused assessments of a client with wrist restraints: While initial assessments must be done by an RN, ongoing focused assessments of restraints can often be delegated to a PN under RN supervision according to facility policies.

B. Supervise a newly hired graduate nurse during an admission assessment: Supervising and evaluating a new nurse’s clinical skills, especially during critical tasks like an admission assessment, requires the judgment and responsibility of a fully licensed RN.

C. Administer PRN oral analgesics to a client with a history of chronic pain: Administering PRN oral medications for stable, chronic conditions is a task that a PN can perform, depending on state regulations and facility protocols.

D. Transport a client who is receiving IV fluids to the radiology department: Transporting stable clients with IV fluids can be delegated to a UAP if the IV is well-established and there are no expected complications.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in this client's plan of care?

Correct Answer is C

Explanation

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?

Correct Answer is B

Explanation

The nurse is teaching a female client about preventive measures for urinary tract infections (UTI). Which information should the nurse include?

Click to indicate which interventions the nurse would include in the plan of care to support the expected outcomes of adequate epidural anesthesia on the mother and the fetus. Each column must have a least one response selected.

Select the 3 findings that would require immediate action from the nurse while the laboring mother is receiving an epidural anesthesia.

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this clients plan of care?

The nurse observes an unlicensed assistive personnel (UAP) begin to provide oral care to an unresponsive client who is at risk for aspiration as seen in the picture. Which instruction(s) should the nurse provide the UAP? Select all that apply.

A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?

Exhibits

Select the 4 assessment findings that require immediate follow up.