Indicate four assessment findings which require immediate follow-up.
BP 85/55.
Hgb 7 g/dL.
Deformed, edematous right lower leg with massive bleeding.
Temp 96.5.
Correct Answer : A,B,C
Choice A rationale
Blood pressure of 85/55 indicates hypotension, which can compromise perfusion to vital organs such as the brain and kidneys. Immediate assessment is necessary to determine the underlying cause, such as dehydration or internal bleeding.
Choice B rationale
Hemoglobin level of 7 g/dL is critically low, falling below the normal range of 12–16 g/dL for women or 13–18 g/dL for men. This reflects severe anemia, which may require urgent intervention, including blood transfusion or addressing the cause of anemia.
Choice C rationale
Massive bleeding from the right lower leg is an emergency due to the risk of hypovolemic shock and significant blood loss. Stabilization of the bleeding site and monitoring for signs of systemic impact is required immediately.
Choice D rationale
A temperature of 96.5°F (35.8°C) may signal mild hypothermia or a systemic condition. While it requires follow-up, it is not as immediately life-threatening as the other findings and therefore does not warrant immediate prioritization.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A rationale
Using a urine filter ensures the recovery of passed stones for laboratory analysis, assisting in identifying stone composition and tailoring prevention strategies.
Choice B rationale
Calcium intake is essential for bone health and reducing oxalate absorption. Avoiding calcium increases oxalate availability, worsening stone formation.
Choice C rationale
Diuretic fluids like coffee promote dehydration and concentration of urine, increasing the risk of stone recurrence. Diuretics should be prescribed for specific stone types.
Choice D rationale
Maintaining hydration prevents urine concentration and the supersaturation of stone-forming crystals, which are primary risk factors for nephrolithiasis.
Correct Answer is A
Explanation
Choice A rationale
Insulin lispro (Humalog) is a rapid-acting insulin that begins to lower blood glucose within 15 minutes of injection, with a peak effect occurring in 30 minutes to 1 hour. It mimics the insulin release following a meal, allowing for better postprandial glucose control.
Choice B rationale
Intermediate-acting insulin, such as NPH, has an onset of 1.5 to 4 hours and provides blood glucose control over an extended period. Insulin lispro does not fit this profile, as it acts quickly and is used for meal-time glucose management.
Choice C rationale
Long-acting insulins, such as glargine or detemir, have no peak and provide basal glucose control for 24 hours or more. Lispro is not suitable for basal control due to its rapid action and short duration.
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