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Patient Data

Exhibits

The nurse is reviewing the client's initial assessment findings.
Which assessment findings require follow-up? Select all that apply.

IV site without redness or swelling

Temperature: 98.8° F (37.1° C)

Respirations: 28 breaths/minute

Heart rate: 92 beats/minute

Taking shallow breaths

Alert and oriented to person, place, time and situation

Pain 8 on a 0 to 10 scale

Blood pressure: 138/82 mm Hg

Answer and Explanation

Correct Answer : C,E,G

A. IV site without redness or swelling: The IV site appears normal with no signs of infiltration or infection, so no immediate follow-up is required. This finding indicates proper IV insertion and maintenance.

B. Temperature: 98.8° F (37.1° C): This is within normal limits and does not indicate fever or infection, so it does not require immediate follow-up.

C. Respirations: 28 breaths/minute: This is above the normal adult range (12–20 breaths/minute) and may indicate respiratory distress due to pain, shallow breathing, or possible pulmonary complications such as atelectasis or pneumonia, requiring close monitoring and follow-up.

D. Heart rate: 92 beats/minute: Slightly elevated but within mild tachycardia range, which could be related to pain or anxiety. It should be monitored but does not require urgent follow-up.

E. Taking shallow breaths: Shallow breathing is concerning in a client with rib fractures, as it increases the risk for hypoventilation, atelectasis, and pneumonia. This requires immediate intervention, such as pain management and respiratory support.

F. Alert and oriented to person, place, time, and situation: Cognitive status is normal, so no follow-up is needed.

G. Pain 8 on a 0 to 10 scale: Severe pain limits deep breathing and mobility, increasing the risk of complications. Pain management should be addressed promptly to improve comfort and respiratory function.

H. Blood pressure: 138/82 mm Hg: Slightly elevated, likely related to pain or stress. Monitor trends, but it does not require immediate follow-up at this time.

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

Explanation

Rationale:
A. Temperature 98.8° F (37.1° C): A normal body temperature indicates resolution of the infection and a positive response to antibiotic therapy for cellulitis. Fever reduction is a key indicator of therapeutic effectiveness.

B. Pain 2 on a 0 to 10 scale, bilateral lower legs described as neuropathic: While pain is low, the description of neuropathic pain unrelated to cellulitis does not reflect improvement in the infection itself, so it is not a primary indicator of therapeutic response.

C. Serum blood glucose 185 mg/dL (10.2 mmol/L): Although improved from the initial hyperglycemia, this level is still above the normal range. It does not directly indicate resolution of cellulitis or therapeutic effectiveness of antibiotic therapy.

D. White blood cell count 11.2 x 103/µL (11.2 x 10⁹/L): The decrease toward normal limits from an elevated WBC demonstrates a positive hematologic response to treatment and reduced systemic inflammation caused by the infection.

E. Capillary refill greater than 3 seconds bilateral lower extremities: Prolonged capillary refill indicates peripheral perfusion deficits. Persistent abnormal refill is not a sign of therapeutic response and may reflect ongoing vascular compromise.

F. Bilateral lower extremities skin warm, dry, and pink: Improvement in skin color, warmth, and absence of edema or erythema reflects resolution of cellulitis and effective local tissue recovery, consistent with therapeutic response.

A. Urge the client to have regular STI screening every two years. B. Answer questions directly and correct any misinformation. C. Clarify that all STIs are transmitted through sexual intercourse. D. Provide counseling that most contraceptives protect against infection.

Correct Answer is B

Explanation

A. Urge the client to have regular STI screening every two years: Screening every two years is insufficient for individuals with recurrent STIs. More frequent testing is recommended to prevent reinfection and detect new infections early.

B. Answer questions directly and correct any misinformation: Providing accurate, evidence-based information helps the client understand STI transmission, prevention, and treatment. Direct responses foster trust, support informed decision-making, and address misconceptions effectively.

C. Clarify that all STIs are transmitted through sexual intercourse: Not all STIs are transmitted solely through intercourse; some, like herpes or HPV, can be transmitted via skin-to-skin contact. This statement could be misleading and does not fully educate the client.

D. Provide counseling that most contraceptives protect against infection: Most contraceptives, such as oral contraceptives or IUDs, do not protect against STIs. Only barrier methods, like condoms, reduce the risk of STI transmission.

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Patient Data Exhibits The nurse is reviewing the client's initial assessment findings. Which assessment findings require follow-up? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis. Select the 3 findings consistent with a therapeutic response to interventions.

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

Explanation

The nurse is caring for a client who tests positive for gonorrhea. The client reports having had prior sexually transmitted infections (STIs). Which response should the nurse provide?

Correct Answer is B

Explanation

The nurse is preparing an older adult client for discharge following cataract extraction. Which instruction should be included in the discharge teaching?

A 15-year-old male client was recently diagnosed with type 1 diabetes mellitus. He tells the nurse that he is having difficulty adhering to his meal plan when he is with his friends. Which nursing intervention is best for the nurse to implement?

Patient Data Exhibits Which of the following findings should the nurse recognize as manifestations of digoxin toxicity? (Select all that apply.)

A client with heart failure is admitted to the medical surgical unit with pneumonia. To reduce cardiac workload, which intervention should the nurse include in the plan of care?

A client receives a prescription for itraconazole. Which statement made by the client requires additional instruction by the nurse?

The nurse is caring for a client with chronic kidney disease (CKD). Which meal selection should the nurse recommend to the client?

The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?

Patient Data

Exhibits

The nurse is reviewing the client's initial assessment findings.
Which assessment findings require follow-up? Select all that apply.