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 D

Explanation

A. Linea nigra is not typically found in older adults.

B. Infants and children do not generally exhibit linea nigra.

C. Adolescents do not commonly have linea nigra.

D. Linea nigra is a dark line that appears on the abdomen of pregnant women due to hormonal changes and increased pigmentation.

A. Assess visual acuity B. Elicit gag reflex C. Checking for pupillary response to light D. Observing for facial symmetry E. Bradycardia

Correct Answer is A

Explanation

A. Assessing visual acuity directly tests cranial nerve II (the optic nerve), which is responsible for vision.

B. Eliciting the gag reflex tests cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve II.

C. Checking for pupillary response to light primarily assesses the function of cranial nerve II but is more associated with cranial nerve III (oculomotor) since it involves the constriction of the pupil. While relevant, it is not the best standalone action for assessing cranial nerve II specifically.

D. Observing for facial symmetry is associated with cranial nerve VII (facial nerve), not cranial nerve II.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Linea nigra is commonly found on the abdomens of:

Correct Answer is D

Explanation

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which action should the nurse take to assess cranial nerve II?

Correct Answer is A

Explanation

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

Exhibits