Try Naxlex NCLEX-RN (Free-Trial)

Patient Data

Exhibits

Click to highlight the assessment findings that require immediate follow up by the nurse.

Client is admitted to the medical floor. She has mild subcostal retractions and is sitting in an upright position. Wheezes are noted throughout the lung fields. The client is pale. She has strong peripheral pulses that are equal bilaterally. Her heart rate is 122 beats/minute, blood pressure 134/85 mm Hg, oxygen saturation 91% on room air.

mild subcostal retractions

Wheezes are noted throughout the lung fields

The client is pale

heart rate is 122 beats/minute

blood pressure 134/85 mm Hg

oxygen saturation 91% on room air

sitting in an upright position

Answer and Explanation

The Correct Answer is ["A","B","C","D","F"]

Mild subcostal retractions: Subcostal retractions indicate that the muscles between the ribs are pulling inward during breathing. This is a sign of increased work of breathing and can indicate respiratory distress.

Wheezes noted throughout the lung fields: Wheezing is a high-pitched whistling sound produced during breathing, typically due to narrowed airways. It indicates airway obstruction, common in asthma exacerbations.

Client is pale: Pallor (pale skin) can indicate reduced oxygenation or perfusion to the tissues, which can occur during respiratory distress.

Heart rate of 122 beats/minute: Tachycardia (elevated heart rate) is a compensatory mechanism in response to decreased oxygen levels or increased respiratory effort.

Oxygen saturation 91% on room air: Oxygen saturation below 94% indicates hypoxemia (low blood oxygen levels), which is a critical finding requiring prompt intervention.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Rationale

A. Ear pain is not typically a common symptom of mononucleosis. Fever, however, is commonly seen in mononucleosis due to the body's immune response to the viral infection.

B. In mononucleosis, there is often an increase in white blood cells (specifically lymphocytes) and an elevated sedimentation rate (ESR). These changes reflect the body's immune response to the Epstein- Barr virus infection.

C. Increased blood urea nitrogen (BUN) and serum creatinine levels are not typically associated with mononucleosis. These markers are more indicative of kidney function and are not directly affected by the viral infection causing mononucleosis.

D. A positive test for Epstein-Barr virus (EBV) antibodies is diagnostic for mononucleosis. Malaise, which is a general feeling of discomfort or illness, is a hallmark symptom of mononucleosis along with other systemic symptoms like fatigue, sore throat, swollen lymph nodes, and sometimes a rash.

A. Ask the client's friend to sign the informed consent since the client is unresponsive. B. Notify the unit manager that an emergency court order is needed to allow surgery. C. Carry on with surgical preparation of the client without a signed informed consent. D. Continue to provide life support until a thorough search for a guardian is completed.

Correct Answer is C

Explanation

Rationale

A. The client's friend may not legally be authorized to provide consent unless they hold medical power of attorney or legal guardianship for the client. Without documentation of such authority, the friend cannot sign the informed consent.

B. In emergency situations where a patient lacks decision-making capacity and there is no available legal guardian or next of kin to provide consent, hospitals may seek a court order to proceed with necessary treatment. However, this could delay emergency treatment.

C. This is based on the legal and ethical understanding that saving the patient's life takes precedence when immediate action is required and consent cannot be obtained.

D. Providing life support ensures that the client's immediate medical needs are addressed while efforts are made to locate a legal guardian. However, unavailability of next of kin should not delay definitive intervention

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?

Correct Answer is D

Explanation

An unresponsive victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save the client's life. The client is accompanied by a close friend, but no family members are available. Which action should the nurse take first?

Correct Answer is C

Explanation

The nurse observes that a client with ascites is dyspneic. Which action should the nurse implement first?

The healthcare provider prescribes the antibiotic cefdinir 300 mg PO every 12 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat?

Exhibits After the nurse assesses the client, the healthcare provider writes prescriptions. The nurse reviews the prescriptions. Which 2 prescriptions should the nurse complete first?

A client with a recent exacerbation of heart failure reports to the nurse feeling uncomfortable and anxious, with a sensation of the flopping in the chest. While waiting for an electrocardiogram (ECG), which assessment is most important for the nurse to obtain?

The nurse is assessing a 4-year-old client with eczema. The child's skin is dry and scaly, and the parent reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child?