Select the 3 findings on day 3 that require immediate follow-up.

Exhibits

PICC line insertion site

Breath sounds

Temperature

Heart rate

Answer and Explanation

Correct Answer : A,C,D

A. PICC line insertion site: The client reports pain, redness, and edema at the PICC line insertion site, which are signs of a possible infection. This finding requires immediate follow-up to prevent complications like bloodstream infection or sepsis.

B. Breath sounds: The client’s breath sounds are clear and unchanged from Day 1, so this finding does not require immediate follow-up.

C. Temperature: The client's temperature has risen to 39 °C (102.2 °F) from 37.2 °C (99 °F) on Day 1. Such a significant increase in temperature indicates a possible infection and needs prompt intervention.

D. Heart rate: The client’s heart rate has increased to 108/min from 66/min, suggesting tachycardia. This could be a response to infection, potentially linked to sepsis, and warrants immediate follow-up.

E. Albumin level: The albumin level has increased to within the normal range, which is a positive trend and does not require urgent intervention.

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Correct Answer is B

Explanation

A. The planning phase involves setting goals and determining interventions based on the assessment data.

B. The assessment phase is where the nurse gathers information about the client's health history, including potential allergies, which is essential for safe care and diagnostic testing.

C. The implementation phase involves carrying out the planned interventions, which would include considerations for allergies but not the initial questioning about them.

D. The evaluation phase assesses the effectiveness of the interventions and the client's response to care, which is not the appropriate time to inquire about allergies.

A. III, IV, VIII B. III, II, VI C. IX, X, XII D. I, I, III

Correct Answer is C

Explanation

A. Cranial nerves III, IV, and VIII are not involved in mouth functions; they primarily deal with eye movements and hearing.
B. Cranial nerves III, II, and VI are involved in vision and eye movement but not in mouth functions.
C. Cranial nerves IX (glossopharyngeal), X (vagus), and XII (hypoglossal) are all tested through functions such as swallowing, speech, and movement of the tongue, which occur in the mouth.
D. Option D incorrectly lists cranial nerve I twice; cranial nerve I (olfactory) is related to the sense of smell, not the mouth.

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Select the 3 findings on day 3 that require immediate follow-up. Exhibits

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

Correct Answer is B

Explanation

When completing a neurological assessment, which cranial nerves are tested within the mouth?

Correct Answer is C

Explanation

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Select the 3 findings on day 3 that require immediate follow-up.

Exhibits