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 A
Explanation
A) Temporary memory loss: Temporary memory loss is a well-known and common side effect following electroconvulsive therapy (ECT). Clients may experience short-term memory issues, such as forgetting events that occurred around the time of the procedure or difficulties recalling information. This side effect is usually temporary and tends to resolve as the brain recovers from the procedure.
B) Voice alteration: Voice alteration is not a typical side effect of electroconvulsive therapy. ECT primarily affects brain function, particularly memory and cognitive processes, and does not have a direct effect on the voice or vocal cords.
C) Tingling of the scalp: Tingling of the scalp is not a common adverse reaction to
electroconvulsive therapy. While there may be some minor physical sensations or discomfort during the procedure, tingling is not a typical side effect associated with ECT.
D) Neck pain: Neck pain is not a usual adverse reaction of electroconvulsive therapy. Some discomfort might occur after the procedure due to muscle tension or the positioning during the therapy, but it is not a common or prominent side effect like memory loss.
Correct Answer is C
Explanation
A) "The client should use a hair dryer on a warm setting to relieve itching inside the cast.": Using a hair dryer on a warm setting to relieve itching inside the cast is not recommended because it could potentially lead to burns or skin irritation. The client should avoid inserting objects inside the cast to scratch, as this could damage the skin or cause an infection.
B) "The client can shower with the cast after 24 hr.": A plaster cast is not waterproof, and the client should avoid getting it wet. Although the cast may feel dry on the outside after 24 hours, it typically takes about 48 hours or longer for a plaster cast to fully dry and harden. Showering with a plaster cast is not safe, as moisture could cause skin irritation or lead to the development of sores or infection.
C) "The client’s extremity should be elevated after the cast is applied.": Elevating the extremity after a cast is applied is a key teaching point to help reduce swelling and improve circulation. This is especially important during the first 24 to 48 hours after cast application. Elevation helps to prevent or manage swelling, which can be a common complication after an injury and cast application.
D) "The client should keep the cast covered until it is dry.": While it is important to keep a cast clean and dry during the drying process, the cast should not be covered with plastic or other materials that could trap moisture. The cast needs air circulation to dry properly, and covering it could lead to the cast becoming too moist, increasing the risk of skin issues or infection.
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