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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 ["B","C","D","E"]

Explanation

A. Changing the glucose monitoring device is unlikely to address the root cause of the elevated blood sugars.
B. Some asthma medications, such as corticosteroids, can increase blood glucose levels. Evaluating these medications is essential.
C. Incorrect technique in monitoring blood glucose can lead to inaccurate readings.

Having the client demonstrate the technique can identify any errors.

D. Ensuring that a new insulin needle is used for each administration is important to prevent infection and ensure proper dosage.

E. Understanding the client’s daily routine, including diet, exercise, and stress levels, can provide insight into factors affecting blood glucose control.

A. IV 0.9% normal saline continuous infusion at 100 B. Daily weights C. Calculation of intake and output D. IV potassium sparing diuretic E. Continuous pulse oximetry monitoring F. Electrocardiogram monitoring

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

A. Given the client's chronic kidney disease and the risk of fluid overload, a high rate of normal saline infusion may not be appropriate without careful assessment and specific indication from the healthcare provider.
B. Monitoring daily weight is essential in managing fluid balance and assessing for potential fluid overload, especially in a child with chronic kidney disease.

C. Accurate measurement of intake and output is crucial in managing fluid balance and monitoring kidney function, particularly in a patient with a history of acute kidney injury and chronic kidney disease.
D. The client already has an elevated potassium level, and administering a potassium-sparing diuretic could worsen hyperkalemia, leading to dangerous cardiac complications.
E. Continuous monitoring of oxygen saturation is important due to the presence of bibasilar infiltrates on the chest X-ray, which could indicate a potential respiratory issue.
F. ECG monitoring is indicated due to the elevated potassium level (5.3 mEq/L), which can cause cardiac arrhythmias. The irregular heart rate further supports the need for ECG monitoring.

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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

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

Explanation

Patient Data Exhibits The healthcare provider has obtained the arterial blood gas and chest X-ray results. New prescriptions have been entered in the client's electronic health record. Nursing Action: Indicated/ Contraindicated

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

The nurse is managing the care of a client with Cushing's syndrome. What intervention(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

An older client is being admitted to a rehabilitation unit from a medical-surgical unit following a left hip replacement. When reviewing the client's prescribed medications, which intervention should the nurse implement first?

While completing an admission assessment for a client with unstable angina, which closed ended questions should the nurse ask about the client's chest pain?

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.