A nurse in a provider's office is caring for a client.
Which of the following findings require follow-up? Select all that apply.
Oxygen saturation
Blood pressure
Pain level
Hematocrit
Temperature
Activity level
Breath sounds
Correct Answer : A,B,D,F
Rationale for Correct Choices:
- Oxygen saturation: The client's oxygen saturation is 94% on room air. While not critically low, given their reported shortness of breath and fatigue, this warrants follow-up. It could be indicative of the severity of their anemia impacting oxygen delivery.
- Blood pressure: The client shows signs of orthostatic hypotension, with a significant drop from 132/60 mm Hg (supine) to 102/50 mm Hg (standing). This change can cause dizziness, falls, and worsened fatigue, and it may be related to anemia or volume depletion that needs evaluation.
- Hematocrit: A hematocrit of 24% is critically low, indicating significant anemia. This aligns with the client’s symptoms of fatigue and dyspnea and requires prompt intervention to determine the underlying cause, such as iron or B12 deficiency.
- Activity level: The client reports shortness of breath with minimal exertion and difficulty keeping up with grandchildren. This functional decline reflects impaired oxygen delivery due to anemia and must be addressed as it affects quality of life and safety.
Rationale for Incorrect Choices:
- Pain level: The client reports no pain or discomfort at this time. While pain is common in rheumatoid arthritis, the current lack of pain does not require further assessment or intervention.
- Temperature: The client's temperature is 37°C (98.6°F), which is normal. There are no signs of infection or inflammation requiring follow-up based solely on this vital sign.
- Breath sounds: Bilateral clear breath sounds indicate that the lungs are not congested and there is no evidence of pulmonary pathology at this time. Therefore, this finding does not require follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hgb 11.5 g/dL (12 to 16 g/dL): While this hemoglobin level is slightly below normal, it is not an immediate priority compared to other more concerning values. Anemia could be addressed later with appropriate interventions but is not life-threatening in this case.
B. Creatinine 3.2 mg/dL (0.5 to 1.1 mg/dL): A creatinine level of 3.2 mg/dL is significantly elevated and indicates possible kidney dysfunction or acute kidney injury. Gentamicin is known to be nephrotoxic, and this level requires prompt attention to prevent further renal damage.
C. Sodium 146 mEq/L (136 to 145 mEq/L): Sodium levels are only slightly elevated and do not represent an immediate concern unless the client has symptoms of hypernatremia (e.g., confusion, seizures). While monitoring is required, it is not as urgent as the creatinine.
D. WBC count 12,000/mm3 (5,000 to 10,000/mm3): A WBC count of 12,000/mm3 is mildly elevated, which could suggest an infection or inflammation. However, this is not the priority compared to the kidney function, which could be compromised by gentamicin therapy.
Correct Answer is B
Explanation
A. Remove weights when pulling the client up in bed: Weights should never be removed from skeletal traction unless ordered by a healthcare provider. Removing weights disrupts the traction's purpose and alignment, potentially causing complications.
B. Check the rope for fraying every 8 hr: Checking the rope for fraying every 8 hours is an appropriate and safe practice in skeletal traction. Ensuring that the rope is intact and functioning properly is essential for maintaining the stability and effectiveness of the traction.
C. Cleanse the pin sites with hydrogen peroxide: Hydrogen peroxide can be too harsh for cleaning pin sites, as it may damage tissue and delay healing. A sterile saline solution is usually preferred for cleaning pin sites unless otherwise prescribed.
D. Inspect the pin sites for infection every 24 hr: Pin site inspections should be done at least once per shift, not just every 24 hours, to promptly detect any signs of infection, as early intervention is key.
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