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A nurse at a provider's office is caring for a client.

Select the 3 findings that require immediate follow-up.

Respiratory findings

Menstrual period

Vaginal spotting

Oxygen saturation

Heart rate

Temperature

Bowel sounds

Abdominal findings

Answer and Explanation

Correct Answer : A,C,H

Respiratory findings: The client has a history of asthma and now presents with slight inspiratory wheezes. Although respiratory rate and oxygen saturation are normal, wheezing indicates airway narrowing, which could worsen rapidly and needs prompt follow-up to prevent an acute asthma exacerbation.
Menstrual period: The client's menstrual period is late by two weeks, but in itself, a late period does not require immediate intervention. It is an important clinical detail but does not demand urgent follow-up unless accompanied by unstable vital signs or other concerning symptoms.
Vaginal spotting: Scant dark red spotting in a client with a late menstrual period raises concern for an ectopic pregnancy, which can be life-threatening if it ruptures. Spotting, combined with abdominal tenderness and delayed menses, demands immediate evaluation to rule out ectopic pregnancy or miscarriage.
Oxygen saturation: The oxygen saturation of 97% on room air is within the normal range for a healthy adult. There is no evidence of hypoxemia, so this finding does not require immediate follow-up despite the client’s mild wheezing.
Heart rate: The heart rate of 90/min is normal and within expected limits for adults. Although the client appears anxious, the heart rate itself does not indicate hemodynamic instability and does not require immediate intervention.
Temperature: A temperature of 37.3° C (99.1° F) is within the normal range and does not suggest active infection or systemic illness. There is no immediate concern based solely on the client’s current temperature reading.
Bowel sounds: Hyperactive bowel sounds can be associated with various conditions, including gastroenteritis, early bowel obstruction, or anxiety. While they contribute to the overall clinical picture of abdominal discomfort, they do not, on their own, necessitate immediate follow-up .
Abdominal findings: Right lower quadrant abdominal tenderness, especially in combination with spotting and late menses, is concerning for an ectopic pregnancy. The possibility of rupture or hemorrhage makes abdominal tenderness a critical finding that requires urgent evaluation.

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Correct Answer is C

Explanation

A. Auscultate the client's lung sounds: While lung sounds are important to assess in clients with heart failure, auscultating lung sounds is not directly required before administering digoxin. The immediate concern with digoxin is its effect on heart rate and rhythm.

B. Check the client's weight: Monitoring weight is important in heart failure management to assess fluid retention, but weight measurement is not necessary immediately prior to administering a dose of digoxin.

C. Check the client's apical pulse: Before giving digoxin, it is critical to assess the client's apical pulse for one full minute. If the pulse is below a specified rate (60 beats/min for adults), the dose may need to be withheld and the provider notified due to the risk of digoxin-induced bradycardia.

D. Obtain the client's oxygen saturation: Oxygen saturation is important in evaluating respiratory function, but it is not a priority action before administering digoxin. The primary safety check is heart rate assessment.

A. Take the medication with crackers. B. Take the medication with an antacid C. Take the medication and then lay down for 30 min. D. Take the medication with calcium-fortified orange juice

Correct Answer is A

Explanation

A. Take the medication with crackers: Taking doxycycline with food can help reduce gastrointestinal irritation, including nausea and vomiting. While it is not usually recommended to take doxycycline with food to ensure full absorption, in this case, eating crackers can help alleviate nausea and make the medication more tolerable.

B. Take the medication with an antacid: Antacids can interfere with the absorption of doxycycline, decreasing its effectiveness. Therefore, it is not recommended to take doxycycline with an antacid.

C. Take the medication and then lay down for 30 min: Lying down after taking doxycycline can increase the risk of esophageal irritation and ulceration. The medication should be taken while sitting or standing, and the client should remain upright for at least 30 minutes afterward.

D. Take the medication with calcium-fortified orange juice: Calcium can bind to doxycycline, decreasing its absorption and effectiveness. Therefore, it is not recommended to take doxycycline with calcium-fortified beverages.

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A nurse at a provider's office is caring for a client. Select the 3 findings that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a dose of digoxin to a client who is experiencing heart failure. Which of the following actions should the take prior to administering this medication?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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A nurse at a provider's office is caring for a client.

Select the 3 findings that require immediate follow-up.