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

Which of the following findings require follow-up? Select all that apply.

Hematocrit

Oxygen saturation

Activity level

Blood pressure

Temperature

Breath sounds

Pain level

Vitamin B12 level

Answer and Explanation

Correct Answer : A,B,C,D,H

Hematocrit: The client's hematocrit level of 24% is significantly low (normal range: 37% to 47%), indicating anemia. This requires follow-up to determine the underlying cause and initiate appropriate treatment, such as iron supplementation or further investigation.
Oxygen saturation: An oxygen saturation level of 94% is slightly low, especially considering the client's reported shortness of breath. Monitoring is necessary to ensure adequate oxygenation and to assess if supplemental oxygen or further respiratory evaluation is needed.
Activity level: The client reports generalized weakness and increased fatigue, particularly becoming short of breath after minimal exertion (e.g., climbing stairs). This decreased activity level is concerning and may indicate cardiovascular or hematological issues, requiring further assessment and follow-up.
Blood pressure: The blood pressure readings indicate orthostatic hypotension, with a drop from 118/60 mm Hg sitting to 102/50 mm Hg standing. This significant drop suggests potential volume depletion or anemia, which requires follow-up to assess fluid status and ensure safety during ambulation.
Vitamin B12 level: The Vitamin B12 level of 159 pg/mL is slightly below the normal range (160 to 950 pg/mL), indicating potential deficiency. This can lead to anemia and neurological issues. Follow-up is needed to evaluate dietary intake and consider supplementation.

Temperature: The client's temperature of 37° C (98.6° F) is within normal limits and does not indicate a need for follow-up. Monitoring for signs of infection or inflammation is important, but this finding is stable.
Breath sounds: The assessment shows clear and present bilateral breath sounds, which indicate no respiratory distress or abnormalities. This finding does not require follow-up.
Pain level: The client reports no pain or discomfort, which is a positive finding and does not necessitate further follow-up. Ongoing assessment for pain should continue, but current findings are stable.

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Correct Answer is C

Explanation

A. Sore throat: A sore throat is a common and expected finding after extubation due to irritation and mild inflammation of the airway. While discomfort may persist, it does not typically require immediate intervention.

B. SaO2 92%: An oxygen saturation of 92% is slightly lower than normal but is generally acceptable in most patients following extubation. Close monitoring is necessary, but immediate intervention is not required unless the saturation continues to decline.

C. Stridor: Stridor is a high-pitched, harsh sound caused by upper airway obstruction, often due to post-extubation laryngeal edema. This is a medical emergency requiring immediate intervention, such as administration of nebulized epinephrine, corticosteroids, or reintubation if severe airway compromise occurs.

D. Rhonchi: Rhonchi are low-pitched, coarse lung sounds caused by mucus or secretions in the airways. This finding may indicate the need for suctioning or respiratory therapy but does not require urgent intervention compared to stridor.

A. Prepare the client for surgery. B. Cover the protrusion with a dressing soaked in 0.9% sodium chloride. C. Obtain the client's vital signs every 5 min until the provider arrives. D. Raise the head of the bed to 20°.

Correct Answer is B

Explanation

A. Prepare the client for surgery: Surgical intervention is required to repair the evisceration, but the immediate priority is to protect the exposed organs from contamination and desiccation by covering them with a sterile saline-moistened dressing.

B. Cover the protrusion with a dressing soaked in 0.9% sodium chloride: This is the priority action to prevent the exposed organs from drying out and reduce the risk of infection. Sterile saline keeps the tissue moist, which is essential for preserving organ viability until surgical repair can be performed.

C. Obtain the client's vital signs every 5 min until the provider arrives: Monitoring vital signs is important to assess for shock, but it is not the first priority. Protecting the exposed abdominal contents takes precedence before initiating continuous monitoring.

D. Raise the head of the bed to 20°: The client should be placed in a low Fowler’s position with knees slightly flexed to reduce abdominal tension, but the most immediate action is to cover the exposed organs with a sterile saline-moistened dressing.

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A nurse in a provider's office is caring for a client. Which of the following findings require follow-up? Select all that apply.

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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

Which of the following findings require follow-up? Select all that apply.