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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

Answer and Explanation

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.

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Correct Answer is ["A","B","E","F"]

Explanation

A. Maintain a safe and private environment for the client – Anticipated. Providing a secure and private setting helps support the client emotionally and ensures confidentiality during a sensitive situation.

B. Request a consult for case management – Anticipated. Case management can coordinate follow-up care, legal support, counseling, and additional resources for the client.

C. Provide resources to the client for the local Alcoholics Anonymous chapter – Contraindicated. There is no indication that the client has an alcohol use disorder. The focus should remain on addressing the sexual assault.

D. Contact children and youth services – Contraindicated. The client is a college student and an adult. There is no mention of minors being involved, so reporting to child protective services is unnecessary.

E. Provide resources for local support services – Anticipated. Connecting the client with crisis centers, advocacy groups, and counseling services is essential for emotional and psychological support.

F. Administer sexually transmitted infection prophylaxis – Anticipated. Post-exposure prophylaxis (PEP) for sexually transmitted infections (STIs), including gonorrhea, chlamydia, and HIV, should be administered to prevent potential infection.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

B. A chest X-ray: The client’s symptoms (cough, blood-tinged sputum, night sweats, fever, and weight loss) are concerning for tuberculosis (TB) or another pulmonary infection. A chest X-ray is a key diagnostic tool to assess for lung abnormalities, including TB infiltrates or cavitations.

D. A Mantoux test: The Mantoux tuberculin skin test (TST) is used to screen for Mycobacterium tuberculosis infection. Given the client’s recent travel to South Africa, a high TB prevalence area, and their symptoms, TB testing is crucial.

Incorrect:

A. A pulmonary function test: This evaluates chronic respiratory conditions like asthma or COPD, but is not a first-line test for an acute cough with systemic symptoms.

C. A nasopharyngeal swab: This is used for diagnosing viral infections like influenza or COVID-19, which are less likely given the client’s blood-tinged sputum and prolonged systemic symptoms.

E. Blood cultures: These are used to detect bacteremia or sepsis, but there is no indication of systemic bacterial infection (e.g., hemodynamic instability, severe leukocytosis).

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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.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client Which of the following interventions should the nurse plan to implement? Select all that apply.

Correct Answer is ["A","B","E","F"]

Explanation

Select words from the choices below to fill in each blank in the following sentence. To further evaluate the client, the nurse anticipates the client will need ____ and ____ .

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

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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.