The practical nurse (PN) is completing a focused assessment of a client who was admitted yesterday with polycythemia vera. Which finding should the PN report to the charge nurse immediately?

Facial pallor, particularly around lips.

Increased heart rate in the last 4 hours.

Dark brown stools in the last 24 hours.

Right lower leg redness and edema.

Answer and Explanation

The Correct Answer is D

Choice A reason: Facial pallor, particularly around the lips, could indicate anemia or poor perfusion, but it is not the most urgent finding in this context. Polycythemia vera typically involves an overproduction of red blood cells, which can actually result in a ruddy complexion rather than pallor. While pallor should be monitored, it does not require immediate reporting compared to other potential complications of polycythemia vera.
Choice B reason: An increased heart rate over the last 4 hours could be a sign of various conditions, such as dehydration, fever, or cardiovascular stress. However, in the context of polycythemia vera, it is not as immediately concerning as symptoms that might indicate thrombotic complications, which are a common and serious risk for these patients. Tachycardia should be monitored, but it is not the most critical finding needing immediate attention.
Choice C reason: Dark brown stools could indicate the presence of digested blood, suggesting gastrointestinal bleeding. While this is an important finding that requires further investigation, it is not as immediately life-threatening as signs of deep vein thrombosis (DVT) in a client with polycythemia vera. Bleeding risks do exist with this condition, but the urgency of DVT symptoms demands prompt intervention to prevent further complications, such as a pulmonary embolism.
Choice D reason: Right lower leg redness and edema are classic signs of deep vein thrombosis (DVT). Clients with polycythemia vera are at increased risk for thrombotic events due to the hyperviscosity of their blood. Reporting this finding immediately is critical, as DVT can lead to serious complications, including pulmonary embolism, which can be life-threatening. Early detection and intervention are essential in managing thrombotic risks in polycythemia vera patients.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Coughing over the catheter site while cleansing the skin is a behavior that indicates the client needs additional teaching. This action can introduce bacteria and other pathogens to the catheter site, increasing the risk of infection. Proper technique should include covering the mouth when coughing and ensuring the area remains as sterile as possible during the cleansing process. Educating the client on the importance of maintaining sterility and preventing contamination is crucial in peritoneal dialysis catheter care.
Choice B reason: Wearing only one sterile glove when cleansing the insertion site may not be ideal, but it does not necessarily indicate a lack of understanding or need for additional teaching. The main concern is ensuring the insertion site is cleaned properly. However, best practice would be to wear two sterile gloves to maintain sterility and reduce the risk of infection.
Choice C reason: Washing hands before opening the 4 by 4 dressing packet is a proper and essential technique in peritoneal dialysis catheter care. This action helps minimize the risk of infection by ensuring that the hands are clean before handling sterile supplies. This behavior does not indicate a need for additional teaching.
Choice D reason: Pouring antiseptic solution and sterile water on sterile dressings is an acceptable practice in peritoneal dialysis catheter care. This step helps disinfect the catheter site and maintain sterility. This behavior does not indicate a need for additional teaching.

A. It detects and maps electrical activity in areas of the brain. B. It uses X-rays and a computer to produce pictures of organs. C. It records eye and muscle movements in response to sounds. D. It graphs electrical impulses to show how the heart is functioning.

Correct Answer is D

Explanation

Choice A reason: This describes an electroencephalogram (EEG), not an ECG. An EEG detects and maps electrical activity in areas of the brain, which is useful for diagnosing conditions such as epilepsy and other brain disorders.
Choice B reason: This describes a computed tomography (CT) scan. A CT scan uses X-rays and a computer to produce detailed images of internal organs and structures. It is not related to the electrical activity of the heart.
Choice C reason: This describes an electromyography (EMG) test or an auditory brainstem response (ABR) test. EMG records electrical activity in muscles, while ABR measures eye and muscle responses to sounds to evaluate the auditory pathways in the brainstem. Neither of these tests is related to recording heart function.
Choice D reason: A 12-lead ECG graphs the electrical impulses generated by the heart as it beats. This test helps evaluate the heart's rhythm, detect any abnormalities, and diagnose various heart conditions such as arrhythmias, myocardial infarctions, and other cardiac issues. By capturing the electrical activity from different angles, the ECG provides a comprehensive picture of the heart's functioning.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The practical nurse (PN) is completing a focused assessment of a client who was admitted yesterday with polycythemia vera. Which finding should the PN report to the charge nurse immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is assisting a client who is performing peritoneal dialysis catheter self-care before being discharged home. Which behavior indicates that the client needs additional teaching?

Correct Answer is A

Explanation

A client receives a 12-lead electrocardiogram (ECG) and asks the practical nurse (PN) what the test is measuring. Which information should the PN explain about this diagnostic test?

Correct Answer is D

Explanation

A client has a PRN prescription for a nasal cannula at 2 to 3 L/minute. The client is wearing a nasal cannula at 2 L/minute and asks the practical nurse (PN) if it can be removed. Which client data is most important for the PN to obtain before responding to the client?

The practical nurse (PN) is assigned to care for a client with Guillain-Barré syndrome (GBS). Which problem has the highest priority for this client's care?

A male client who recently had a myocardial infarction tells the practical nurse (PN) that he refuses to give up his habit of smoking two packs of cigarettes daily. Which intervention(s) should the PN implement? Select all that apply.

When providing preoperative care for a client with an abdominal aneurysm, changes in which assessment finding are most important for the practical nurse (PN) to report to the registered nurse (RN)?

A client with diabetes mellitus is admitted with an infected foot pressure injury. During a routine assessment, the practical nurse (PN) notes a pattern of deep, rapid respirations and a fruity breath odor. Which action should the PN take first?

A client is recovering from a transurethral prostatectomy. Which activity should the practical nurse (PN) reinforce with the client to limit until after the first postoperative visit?

A client who received a renal transplant two weeks ago is experiencing a rapid and sudden decrease in urine output in the catheter. Which assessment(s) should the practical nurse (PN) complete before notifying the charge nurse? Select all that apply.

A client is diagnosed with a seizure disorder and is completing testing before discharge from the healthcare facility. What information should the practical nurse (PN) reinforce to avoid the incidence of seizure episodes? Select all that apply.