The practical nurse (PN) checks the face of an older adult client who is wearing a nasal cannula. Which new finding is most important for the PN to report to the charge nurse?
Redness of the cheek under the cannula.
Dry, cracked mucous membranes.
Encrustations on both of the eyelids.
Drooping of the right side of the mouth.
The Correct Answer is D
A. Redness of the cheek under the cannula: Indicates skin irritation, but can usually be managed locally; not the most urgent.
B. Dry, cracked mucous membranes: Suggests dryness from oxygen but not immediately life-threatening.
C. Encrustations on both of the eyelids: Could indicate infection or poor hygiene but less urgent than neurological changes.
D. Drooping of the right side of the mouth: This could indicate a new-onset stroke (facial droop), which is a neurological emergency requiring immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. If your baby is voiding pale straw-colored urine 6 to 10 times a day, your milk is sufficient: Frequent wet diapers with light-colored urine is a reliable sign of adequate intake.
B. Weigh the baby before and after each feeding: Impractical for home use; reserved for special monitoring.
C. Offer the baby an extra bottle of milk after her feeding: Not recommended; interferes with breastfeeding and demand-supply regulation.
D. If you're concerned, bottle feed your baby so that you can see how much milk your daughter is taking: Not the first-line response; undermines breastfeeding.
Correct Answer is B
Explanation
A. Red streaks from wound: Could indicate lymphangitis but not immediately life-threatening.
B. Urine output 20 mL/hour: Indicates possible septic shock with decreased renal perfusion - urgent finding.
C. Purulent wound drainage: Suggests infection but expected in an infected bite; not immediately life-threatening.
D. Blood pressure 100/60 mm Hg: Low-normal BP; not yet critical unless accompanied by other shock signs.
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