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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 B

Explanation

Rationale:

A. Review his glycosylated hemoglobin level 3 months after the teaching session: HbA1c reflects long-term glucose control but is influenced by many factors beyond injection technique. It is not an immediate or specific indicator of how well the adolescent learned the injection procedure.

B. Observe him as he demonstrates the self-injection technique to another diabetic adolescent: Direct observation allows the nurse to assess the adolescent’s actual skill performance, technique accuracy, and confidence. This provides the most immediate and practical measure of teaching effectiveness.

C. Ask the adolescent to describe his level of comfort with injecting himself with insulin: Self-reported comfort is subjective and does not guarantee proper technique. The adolescent may feel comfortable but still make critical errors during injection.

D. Have the adolescent list the procedural steps for safe insulin administration: Listing steps tests knowledge recall but not motor skills or application. The adolescent may know the steps but struggle with actual injection, making demonstration a more effective evaluation method.

A. Continue to monitor vital signs every hour. B. Apply oxygen via nasal prongs at 4 L/minute. C. Recheck all vital signs including core temperature. D. Expose client's extremities and apply ice packs to axilla. E. Page the admitting anesthesiologist STAT.

Correct Answer is ["B","C","E"]

Explanation

A. Continue to monitor vital signs every hour: Simply continuing routine monitoring is not sufficient in response to a sudden and significant temperature spike. A rapid rise in temperature shortly after surgery may indicate malignant hyperthermia or sepsis, both of which require immediate intervention.

B. Apply oxygen via nasal prongs at 4 L/minute: Supplemental oxygen is important during a suspected hypermetabolic crisis such as malignant hyperthermia. Increased metabolic activity raises oxygen demand, and oxygen therapy supports tissue perfusion and reduces hypoxia risk.

C. Recheck all vital signs including core temperature: A rapid reassessment helps confirm the rise in temperature and detect other abnormalities like tachycardia, hypotension, or increased end-tidal CO₂. Verifying core temperature also helps determine the severity of the response and guides further action.

D. Expose client's extremities and apply ice packs to axilla: External cooling may be helpful but should not be done before confirming the diagnosis. It may delay more appropriate measures like administering dantrolene if malignant hyperthermia is suspected, and should only be part of a broader management plan.

E. Page the admitting anesthesiologist STAT: A sudden spike in temperature shortly after surgery raises concern for malignant hyperthermia, a rare but life-threatening emergency. Immediate anesthesiologist notification is critical to initiate rapid treatment and administer dantrolene if needed.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a male adolescent recently diagnosed with type 1 diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate the effectiveness of the teaching?

Correct Answer is B

Explanation

Following a bowel resection, a client's tympanic temperature was 97.6° F (36.4° C) on admission to the postanesthesia care unit (PACU). Thirty minutes later, the temperature is 101.6°F (38.7°C). Which intervention(s) should the nurse implement? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Exhibits Drag from statement options to complete the sentence. To assess outcomes, the nurse should consider information reported by the client and caregiver and focus on evaluating the client's dropdown and dropdown

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Exhibits

Select the 4 assessment findings that require immediate follow up.