Try Naxlex NCLEX-RN (Free-Trial)

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.

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 A

Explanation

A. Scoliosis is a lateral curvature of the spine. It is commonly assessed during routine physical examinations, especially in adolescents.
B. Lordosis refers to an exaggerated inward curvature of the spine, typically in the lumbar region.
C. Torticollis is a condition characterized by a tilt of the head to one side due to the shortening of muscles on one side of the neck.
D. Kyphosis is an exaggerated outward curvature of the thoracic spine, leading to a rounded upper back.

A. Remove the transdermal patch until the vomiting subsides. B. Reposition the transdermal patch to the client's trunk. C. Explain that this is a side effect of the medication in the patch. D. Notify the client's healthcare provider of the vomiting.

Correct Answer is D

Explanation

A. Removing the scopolamine patch is not indicated without consulting the healthcare provider.
B. Repositioning the patch is not necessary as it is properly placed for its intended effect.
C. While nausea and vomiting are potential side effects of scopolamine, it's important to notify the healthcare provider to determine the appropriate next steps.
D. Notifying the healthcare provider allows for further evaluation and possible adjustment of the client's postoperative antiemetic regimen.

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

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

A nurse is assisting with a routine physical examination of an adolescent. The provider observes a lateral curvature of the spine. The nurse should expect the provider to document which of the following disorders?

Correct Answer is A

Explanation

Four hours after surgery, a client reports nausea and begins to vomit. The nurse notes that the client has a scopolamine transdermal patch applied behind the ear. Which action should the nurse take?

Correct Answer is D

Explanation

The nurse is caring for a client with pneumonia who now develops initial signs of septic shock and multi-organ failure. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care?

A client receives a prescription for acetaminophen 1,000 mg PO every 8 hours PRN for pain. The bottle is labeled "Acetaminophen for Oral Suspension, USP 500 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)

A client with chronic kidney disease reports to the nurse of feeling increasingly tired. The client receives injections for epoetin alfa three times a week. Which laboratory value should the nurse review?

Exhibits The nurse is caring for the client. Which of the following assessment findings should the nurse prioritize?

A 2-year-old is brought to the emergency department (ED) with a history of several days of rhinitis and now exhibits a productive barking cough and difficulty breathing. Which additional finding should alert the nurse that the child is experiencing respiratory distress?

The nurse is caring for an immobile client after spinal surgery. Which action is most important for the nurse to take to prevent postoperative complications?

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?

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.