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Reference Range:

Body mass index (BMI) [18 to 24.9 kg/m3]

Click to highlight the findings that require follow up

Neurological: Alert and oriented. Agitated. Denies headaches.

Cardiovascular: Reported chest pain described as pressure and tightness that is unrelieved with rest. Rapid regular rhythm. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.

Respiratory: Rapid and shallow breaths. Clear breath sounds throughout bilateral lungs.

Alert and oriented

Agitated

Denies headaches

Reported chest pain described as pressure and tightness that is unrelieved with rest. Rapid regular rhythm

Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds

Rapid and shallow breaths

Clear breath sounds throughout bilateral lungs

Answer and Explanation

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

Agitated behavior: Agitation may be an early sign of hypoxia or decreased cardiac output. In the context of suspected cardiac ischemia, this could signal worsening perfusion and should be addressed immediately.
Chest pain unrelieved by rest: Ongoing chest pain at rest, especially pressure-like, suggests unstable angina or myocardial infarction. This is a critical red flag requiring prompt cardiac workup and treatment.
Rapid heart rate: A heart rate of 121 bpm is tachycardic and may reflect sympathetic activation due to pain, anxiety, or decreased cardiac output. It may also increase myocardial oxygen demand, worsening ischemia.
Respiratory rate increased with shallow breathing: This may be a compensatory response to hypoxia or pain. Shallow respirations can reduce oxygen exchange, contributing to further cardiac strain.
Oxygen saturation of 92% on room air: This is below normal and may indicate early hypoxemia. In the context of chest pain and increased respiratory rate, it requires oxygen therapy and further investigation.
Pain rated 7/10, progressive and unrelieved: Ongoing chest pain not relieved with rest or time may signify myocardial injury. This symptom is critical and should be continuously monitored and managed urgently.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

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

Explanation

A. Insert a second large bore IV catheter: This may be necessary in a trauma setting if volume resuscitation is needed, but there is no indication of hemodynamic instability or bleeding in this scenario. It is not the most immediate or essential response to new neurologic findings.

B. Schedule a repeat CT scan: A dilated, non-reactive pupil and change in neurologic status may indicate increased intracranial pressure or new bleeding. A repeat CT scan is critical to evaluate for worsening brain injury or cerebral herniation.

C. Apply artificial tear drops to left eye: A non-reactive pupil suggests cranial nerve involvement, possibly impairing the eye's ability to blink. To protect the cornea from drying and ulceration, artificial tears or eye protection is appropriate.

D. Place in lateral Trendelenburg position: Trendelenburg position is contraindicated in clients with suspected increased intracranial pressure, as it may worsen cerebral edema. The head should be elevated, not lowered.

E. Repeat Glasgow coma assessment: Frequent reassessment of neurologic status using the Glasgow Coma Scale helps detect early signs of deterioration and guides the urgency of interventions such as imaging or surgical evaluation.

A. Catheter tubing. B. Client's bladder. C. Urinary meatus. D. The client's bed.

Correct Answer is D

Explanation

A. Catheter tubing: While catheter tubing can become contaminated and contribute to infection, it is not the primary reservoir in this scenario where the catheter bag resting on the bed surface likely introduced external pathogens.

B. Client's bladder: The bladder is typically sterile unless an infection has already occurred; in this case, the infection is secondary to contamination from an external source, not an internal origin.

C. Urinary meatus: The urinary meatus can harbor some normal flora, but it is not considered the source or reservoir of the infection linked to the catheter bag being placed on the bed.

D. The client's bed: The bed, an external environment, can harbor bacteria that contaminate the catheter bag and ascend into the urinary tract, making it the reservoir for the infection in this situation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

A client's catheter bag was left on the client's bed for a prolonged period of time, and the client develops a urinary tract infection (UTI). In evaluating the cause of the infection, which should the nurse identify as the infection reservoir?

Correct Answer is D

Explanation

A female client presents to the clinic with a fever and sore throat as well as a rash on the hands, palms, and the soles of the feet. The client reports having intercourse once with a new partner approximately 8 weeks ago. Which condition should the nurse suspect?

A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair. Which intervention is most important for the nurse to include in the plan of care?

A client with generalized anxiety disorder does not want to communicate with friends, smokes 2 to 3 packages of cigarettes a day, and describes difficulty concentrating at work. Which coping strategy should the nurse include in the plan of care?

The nurse is completing the admission assessment of a client with multiple sclerosis (MS). Which finding(s) should be reported to the healthcare provider immediately? Select all that apply.

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

When assessing a client who had a transurethral resection of the prostate (TURP) one day ago, the nurse observes that his scrotum and penis are edematous. Which intervention(s) should the nurse implement? Select all that apply.