Focused Data Collection And Reporting - NCLEX Pn

1. Which finding in the affected extremity is the most urgent to report to the RN?
   Answer: Client reports numbness and tingling in the foot. Numbness and tingling (paresthesia) is a sign of nerve compression or circulatory impairment and can be an early indicator of compartment syndrome. This finding is the most urgent to report for immediate evaluation. Swelling and bruising are expected post-op findings. Normal capillary refill and a present but slightly weaker pulse, while monitored, are less immediately concerning than neurological symptoms that could indicate compartment syndrome.
2. During data collection, which finding is most important to report to the RN?
   Answer: Pink, frothy sputum with coughing. Pink, frothy sputum is a hallmark sign of acute pulmonary edema, a life-threatening complication of heart failure. This indicates fluid is filling the alveoli and requires immediate intervention. While fatigue, adequate urine output, and peripheral edema are common findings in heart failure, they do not signify the same level of acute danger as pink, frothy sputum.
3. Which finding is abnormal and requires reporting to the RN?
   Answer: Nasal flaring with respirations. Nasal flaring is a sign of respiratory distress in a newborn and indicates increased work of breathing. This is an abnormal finding that must be reported for further evaluation. Acrocyanosis (bluish hands and feet) is a normal finding in the first 24 hours of life. A respiratory rate of 30-60 breaths/minute and a heart rate of 110-160 beats/minute are within normal limits for a newborn.
4. Which client report is most important to communicate to the RN as a potential sign of lithium toxicity?
   Answer: Experiencing coarse hand tremors and confusion. Coarse hand tremors, confusion, and ataxia are signs of moderate to severe lithium toxicity, which requires immediate medical attention. Thirst, fine hand tremors, and mild nausea are common and expected side effects of lithium at therapeutic levels. The LPN must be able to distinguish between expected side effects and signs of toxicity.
5. Over the past 4 hours, the LPN notes the total urine output is 80 mL. Which action should the LPN take first?
   Answer: Check the catheter tubing for kinks or obstruction. A urine output of 80 mL over 4 hours (20 mL/hr) is below the minimum acceptable rate of 30 mL/hr. Before reporting, the LPN should first perform a focused data collection to rule out a simple, correctable problem. The most common cause of suddenly decreased output from a catheter is an obstruction, such as a kink in the tubing. After checking the tubing, the LPN would then report the finding to the RN if the output does not improve.
6. What is the priority data for the LPN to collect and report to the RN?
   Answer: Capillary blood glucose every 6 hours. TPN solutions contain a high concentration of dextrose, which places the client at significant risk for hyperglycemia. Monitoring blood glucose levels at regular intervals (typically every 4-6 hours) is the priority to detect and manage this common and serious complication. While weight, I&O, and dressing assessment are important, managing the immediate metabolic risk of hyperglycemia is the highest priority.
7. Which change in the client's status is most important to report to the RN?
   Answer: New onset of confusion and agitation. In an older adult, new onset of confusion or agitation is often the earliest sign of hypoxia or worsening infection. This change in mental status is a critical finding that must be reported immediately. The other findings (productive cough, acceptable oxygen saturation, and low-grade fever) are expected findings for a client with pneumonia.
8. Which data collection finding requires immediate notification of the RN?
   Answer: Saturating one perineal pad in 30 minutes. Saturating a perineal pad in one hour or less is a sign of excessive bleeding and potential postpartum hemorrhage, a life-threatening condition. This finding requires immediate intervention. Lochia rubra, a firm fundus at the umbilicus, and moderate perineal pain are all normal findings in the immediate postpartum period.
9. Which laboratory value is the highest priority for the LPN to report to the RN?
   Answer: Serum potassium of 6.5 mEq/L. A serum potassium of 6.5 mEq/L is critically high (hyperkalemia) and can cause life-threatening cardiac dysrhythmias. This finding is the top priority to report. While elevated creatinine, elevated BUN, and low hemoglobin (anemia) are expected findings in a client with stage 4 CKD, they do not pose the same immediate life-threatening risk as severe hyperkalemia.
10. Which data collection finding would prompt the LPN to withhold the medication and report to the RN?
    Answer: Client reports seeing yellow-green halos around lights. Visual disturbances, such as seeing yellow-green halos, are a classic sign of digoxin toxicity. This finding requires withholding the dose and notifying the RN for further assessment and orders. An apical pulse of 64 is acceptable (usually held for <60), the blood pressure is normal, and the potassium level is within the normal range.
11. A 52-year-old client with a new prescription for trimethoprim-sulfamethoxazole for a urinary tract infection has a history of sulfonamide allergy listed as 'rash as a child' and currently takes hydrochlorothiazide for hypertension. After the first dose, the client reports itching and the nurse observes swelling of the lips; vital signs are blood pressure 118/74 mm Hg, heart rate 102/min, respiratory rate 22/min, oxygen saturation 93% on room air. What symptom change should be documented and communicated?
    Answer: Swelling of the lips after the first dose This question tests focused data collection and reporting skills in allergic reaction assessment. The key priority is recognizing signs of anaphylaxis requiring immediate intervention. Swelling of the lips (B) indicates angioedema, which can progress rapidly to airway obstruction and is a medical emergency, especially with the respiratory rate of 22/min and oxygen saturation of 93%. While itching (A) is concerning, it's less severe than angioedema, childhood rash history (C) is already documented, and blood pressure (D) remains stable. The decision-making principle is that signs of airway involvement in allergic reactions require immediate reporting and intervention. When documenting allergic reactions, always prioritize findings that indicate progression to anaphylaxis, particularly facial or airway swelling.
12. Which combination of vital sign changes is the highest priority to report to the RN?
    Answer: Blood pressure 170/80 mmHg, heart rate 50/min, respiratory rate 10/min. The combination of hypertension (with a widening pulse pressure), bradycardia, and decreased respirations constitutes Cushing's triad, a late and ominous sign of increased intracranial pressure (ICP). This indicates pressure on the brainstem and is a neurological emergency that must be reported immediately. The other vital sign sets represent potential hypovolemia (C), normal ranges (D), or mild tachycardia/tachypnea (A), which are less critical in this context.
13. Which finding suggests phenytoin toxicity and should be reported to the RN?
    Answer: Unsteady gait and nystagmus. Central nervous system side effects such as ataxia (unsteady gait) and nystagmus (involuntary eye movements) are early signs of phenytoin toxicity. These findings should be reported to the RN. Gingival hyperplasia is a common, long-term side effect but not a sign of acute toxicity. A rash could be a serious adverse effect (like Stevens-Johnson syndrome) but ataxia and nystagmus are more specific to toxicity. A level of 15 mcg/mL is within the therapeutic range (10-20 mcg/mL).
14. Which client statement is the most critical to report to the RN immediately?
    Answer: "My pain is getting worse even after the pain medication." Severe pain that is unrelieved by analgesics is a classic sign of compartment syndrome, a serious complication that can lead to permanent muscle and nerve damage. This finding is the highest priority. Cold toes, a feeling of tightness, and general discomfort are expected to some degree after cast application, but unrelieved and escalating pain is a red flag for a medical emergency.
15. The LPN collects data on the client. Which finding is the priority to report to the registered nurse (RN)?
    Answer: A firm, distended abdomen. A firm, distended abdomen after abdominal surgery can indicate internal hemorrhage or peritonitis, which are life-threatening complications requiring immediate intervention. Absent bowel sounds are expected for up to 24-48 hours post-operatively due to anesthesia and bowel manipulation. Pain rated as 5/10 is expected after major surgery and should be managed with prescribed analgesics. Serosanguineous drainage is a normal finding on a surgical dressing.
16. Which laboratory value requires immediate reporting to the RN?
    Answer: International Normalized Ratio (INR) of 5.2. The therapeutic INR for a client on warfarin for atrial fibrillation is typically 2.0 to 3.0. An INR of 5.2 is critically high and indicates an excessive anticoagulant effect, placing the client at a significant risk for bleeding. This finding must be reported immediately. The platelet count, PT (non-standardized), and hemoglobin values are within normal limits.
17. Which laboratory value is most concerning and should be reported to the RN?
    Answer: Potassium 2.9 mEq/L. Furosemide is a potassium-wasting loop diuretic. A serum potassium level of 2.9 mEq/L is low (hypokalemia) and puts the client at risk for life-threatening cardiac dysrhythmias. This is the most concerning finding and must be reported. The sodium, calcium, and BUN levels are within normal limits.
18. Which data collection finding would indicate a life-threatening complication that must be reported immediately?
    Answer: The client is observed vomiting a large amount of bright red blood. Vomiting bright red blood (hematemesis) indicates a ruptured esophageal varix, which is a massive hemorrhage and a medical emergency. This is the most acute, life-threatening finding. Jaundice, ascites, and palmar erythema are all chronic signs of cirrhosis but do not represent the same immediate danger as active bleeding.
19. What is the priority data for the LPN to collect and report before administering the insulin?
    Answer: Current capillary blood glucose level. The client's symptoms (diaphoresis, shakiness) are classic signs of hypoglycemia. Administering insulin to a hypoglycemic client can be fatal. The priority action is to check the capillary blood glucose level to confirm hypoglycemia and report the finding before any insulin is given. The other data points are relevant but not the immediate priority.
20. Which data point, if reported by the client, is most important for the LPN to report to the RN immediately?
    Answer: The client states, "My pain is suddenly gone." A sudden cessation of pain in a client with appendicitis is a red flag for appendix rupture. This can lead to peritonitis, a life-threatening infection. This change is the most critical to report immediately. Nausea, severe pain, and anorexia are all classic, expected symptoms of appendicitis but do not indicate the same acute change as a sudden relief of pain.

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