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The nurse is assisting in the care of an adolescent athlete in the emergency department.

Exhibits
Select the 2 findings that require immediate follow-up.

Blood pressure

Heart rate

Level of consciousness

BUN level

Sodium level

Answer and Explanation

Correct Answer : C,E

A. Blood pressure
124/72 mm Hg is normal.

B. Heart rate
64/min is normal.

C. Level of consciousness
Disorientation and hallucinations ("looking for the cat") suggest altered mental status, possibly from hypernatremia or hyperosmolality.

D. BUN level
14 mg/dL is within normal range.

E. Sodium level
Sodium of 150 mEq/L is elevated. Hypernatremia can cause neurological changes and must be corrected cautiously.

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

Explanation

A. Administer Rh, D immune globin prior to surgery
If client is Rh-negative, Rhogam is necessary to prevent isoimmunization.

B. Obtain a complete blood count
Needed preoperatively to assess for anemia, especially with ongoing bleeding.

C. Remind client to be NPO prior to surgery
Standard pre-op instruction to reduce risk of aspiration under anesthesia.

D. Explain the surgical procedure to the client
Explaining procedures is the provider’s responsibility, not the nurse’s.

E. Prepare client for insertion of 18-gauge peripheral IV
A large-bore IV is needed for fluid resuscitation and possible blood transfusion.

F. Verify consent form is signed by the client
It is the nurse’s role to confirm that consent was obtained and documented.

G. Assist with administration of AB positive blood products if needed
The client must receive type-specific blood unless it’s an emergency, in which case O negative is preferred.

A. Respiratory rate B. Pedal pulses C. Breath sounds D. Oxygen saturation E. Movement of right foot F. Heart rate

Correct Answer is ["A","C","D","F"]

Explanation

A. Respiratory rate
Increased to 28/min from baseline of 18/min. This may indicate respiratory distress or pulmonary embolism.

B. Pedal pulses
Still 2+, no change noted - not an immediate concern.

C. Breath sounds
Crackles at the bases are new and could suggest fluid overload, atelectasis, or early pneumonia/PE.

D. Oxygen saturation
Dropped to 88% on room air, indicating hypoxia, which requires urgent intervention.

E. Movement of right foot
No change - sensation and movement intact, not an urgent issue.

F. Heart rate
Increased from 88 to 112/min. Can indicate pain, infection, or respiratory compromise.

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The nurse is assisting in the care of an adolescent athlete in the emergency department. Exhibits Select the 2 findings that require immediate follow-up.

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Naxlex Comprehensive Predictor Exams

The nurse has reviewed the Nurses' Notes and Provider Prescriptions at 1100 and Diagnostic Results on Day 3. Exhibits The nurse is preparing the client for surgery. Which of the following actions should the nurse take? Select all that apply.

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

Explanation

A nurse is assisting with the care of a client. Exhibits Select the 4 findings that require immediate follow-up.

Correct Answer is ["A","C","D","F"]

Explanation

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The nurse is assisting in the care of an adolescent athlete in the emergency department.

Exhibits
Select the 2 findings that require immediate follow-up.