A nurse assisting with the care of a client who is admitted to the medical-surgical unit.
The nurse is reviewing the client's laboratory findings and vital signs.
Select the 5 findings that require immediate follow-up.
Respiratory rate
Stool results
Heart rate
Temperature
WBC count
Blood pressure
Hemoglobin and hematocrit
Current medications
Correct Answer : B,C,F,G,H
B. Stool results: A positive hemoccult test indicates gastrointestinal bleeding, likely due to a peptic ulcer. Immediate follow-up is needed to assess for ongoing blood loss and the potential for hemorrhagic complications.
C. Heart rate: The tachycardia (118/min) suggests a compensatory response to hypovolemia from gastrointestinal bleeding. This requires prompt intervention to prevent hemodynamic instability.
F. Blood pressure: Hypotension (90/50 mm Hg) is concerning for volume depletion due to chronic or active gastrointestinal bleeding. This requires immediate follow-up to prevent shock.
G. Hemoglobin and hematocrit: A hemoglobin of 9.1 g/dL and hematocrit of 27% indicate anemia, likely due to gastrointestinal blood loss. Further evaluation and potential blood transfusion may be required.
H. Current medications: Ibuprofen use is a major risk factor for peptic ulcer disease and gastrointestinal bleeding. Immediate follow-up is needed to discontinue NSAIDs and initiate appropriate ulcer management.
Incorrect:
A. Respiratory rate: A rate of 18/min is within the normal range and does not require urgent follow-up.
D. Temperature: A temperature of 37.5°C (99.5°F) is slightly elevated but not clinically significant for immediate intervention.
E. WBC count: The WBC count is within the normal range, making it less of an immediate concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) "Individuals who have this disorder have a flat affect.": A flat affect, which refers to a lack of emotional expression, is more characteristic of conditions like depression or schizophrenia rather than delirium. Delirium typically involves fluctuating levels of consciousness, confusion, and altered attention, but a flat affect is not a defining feature.
B) "This disorder is characterized by a sudden onset of mental confusion.": This statement is correct. Delirium is characterized by a rapid onset of symptoms, including confusion, disorientation, and changes in cognition. The acute nature of delirium distinguishes it from other conditions like dementia, which develops gradually over time.
C) "Individuals who have this disorder speak at a slow pace.": While some individuals with delirium may speak slowly due to confusion or disorientation, this is not a defining characteristic of the disorder. Delirium can cause a variety of speech patterns, including rambling, incoherence, or even rapid speech depending on the individual’s cognitive state.
D) "This disorder is not reversible.": This statement is incorrect. Delirium is typically reversible if the underlying cause (such as infection, dehydration, or medication side effects) is identified and treated. Unlike progressive disorders like dementia, delirium can often be resolved with appropriate medical intervention.
Correct Answer is ["B","C","E"]
Explanation
A. Chronic health condition: The client has a history of Parkinson’s disease and anxiety, which are relevant but not immediate concerns. Chronic conditions require long-term management rather than urgent intervention.
B. Current level of consciousness: The client is restless and not following commands, which may indicate hypoxia, worsening infection, or sepsis. A change in mental status is a critical finding requiring immediate evaluation.
C. Oxygen saturation level: The oxygen saturation is 89% on room air, which is below the normal range (≥95%). This suggests respiratory compromise, likely due to pneumonia, requiring urgent oxygen support.
D. Heart rate: The client has a heart rate of 104/min, which is mildly elevated and expected due to fever and respiratory distress. However, it is not the most critical concern compared to respiratory distress and altered mental status.
E. Respiratory rate: The respiratory rate is 30/min, indicating tachypnea and increased work of breathing, suggesting respiratory distress or impending respiratory failure. This requires immediate intervention.
F. Tremors: Tremors are a common finding in Parkinson’s disease and do not require immediate intervention.
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