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Patient's data

Exhibits
The nurse obtains verbal handoff from the outpatient clinic nurse, reviews the electronic health record, and completes an initial assessment including vital signs.

Which assessment findings require follow up by the nurse? Select all that apply.

Skin pale and diaphoretic

Respiratory rate 36 breaths/minute

Blood pressure 140/86 mm Hg

Temperature 101.1° F (38.4" C) orally

Bilateral basilar crackles

Bilateral radial pulses bounding

Heart rate 117 beats/minute and irregular

Oxygen saturation 98% on room air

Answer and Explanation

Correct Answer : A,B,C,D,E,G

A.   Skin pale and diaphoretic: These can be signs of dehydration, infection, or other conditions.
B.   Respiratory rate 36 breaths/minute - This is elevated, especially for a child, indicating potential respiratory distress or infection, particularly given the patient's history and current fever.
C.   Blood pressure 140/86 mm Hg - This is high for a 7-year-old and could indicate fluid overload or other complications related to his chronic kidney disease.
D.   Temperature 101.1° F (38.4° C) orally - Continued fever despite antipyretic treatment suggests ongoing infection or inflammation needing further evaluation.
E.   Bilateral basilar crackles - This could suggest fluid in the lungs (pulmonary edema), which is critical given the patient's possible fluid overload and high blood pressure.
F.   Bilateral bounding radial pulses is not necessarily a cause of concern in the above case.

G. Heart rate 117 beats/minute and irregular - An elevated and irregular heart rate in a child is concerning and could indicate cardiovascular stress or electrolyte imbalances, which need addressing given his elevated potassium levels.
H. Oxygen saturation 98% on room air: Normal oxygen saturation suggests adequate gas exchange.

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Correct Answer is A

Explanation

A. Reminding the UAP to continue rubbing the hands together until they are dry ensures proper use of the hand rub, which is effective when fully dry.
B. Handwashing with soap and water is necessary after certain activities (e.g., after using the restroom, or when hands are visibly soiled), but using an alcohol-based hand rub is appropriate for routine hand hygiene.
C. Supervising in the next client's room is less direct and immediate than ensuring proper technique now.
D. Wearing gloves for all clients is not necessary and does not replace proper hand hygiene.

A. Low-fat dairy products. B. Fresh fruits and vegetables. C. Iron-rich meals. D. Water and herbal teas.

Correct Answer is A

Explanation

A: Dairy products such as milk, yogurt, and cheese are rich sources of calcium, which is essential for bone health and can help prevent osteoporosis, especially in older adults.
B: While fruits and vegetables are important for overall health, they do not provide significant amounts of calcium, which is the primary nutrient needed for preventing osteoporosis.
C: Iron-rich meals are important for preventing anemia but do not directly contribute to bone health and prevention of osteoporosis.
D: While hydration is important for overall health, water and herbal teas do not provide significant amounts of calcium needed for bone health.

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Patient's data Exhibits The nurse obtains verbal handoff from the outpatient clinic nurse, reviews the electronic health record, and completes an initial assessment including vital signs. Which assessment findings require follow up by the nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-based hand rub while leaving a client's room after taking vital signs. Which action should the nurse take?

Correct Answer is A

Explanation

The nurse is teaching an older client about the prevention of osteoporosis. Which foods should the nurse recommend to the client to increase in the diet?

Correct Answer is A

Explanation

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Which is the priority nursing problem for a client with hypoparathyroidism?

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The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention?

The nurse is providing teaching to a client admitted with a blood glucose level of 580 mg/dL (32.2 mmol/L) about preventing complications related to diabetes mellitus. Which statement by the client indicates understanding? Reference Range: Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Patient's data

Exhibits
The nurse obtains verbal handoff from the outpatient clinic nurse, reviews the electronic health record, and completes an initial assessment including vital signs.

Which assessment findings require follow up by the nurse? Select all that apply.