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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Chest tube with a drainage system: A chest tube is typically used for pneumothorax or pleural effusion, not as a routine treatment for cystic fibrosis. While some clients with severe lung disease may require one in emergencies, it is not standard home care equipment.
B. NG tube with suction apparatus: While some clients with cystic fibrosis may require enteral feeding for nutritional support, an NG tube with suction is not a standard home intervention. Suctioning is generally needed for acute gastrointestinal obstruction rather than routine CF management.
C. Chest physiotherapy vest: This device helps loosen and mobilize thick mucus from the airways, improving airway clearance and reducing the risk of infections. It is a critical component of daily CF management and is commonly used in home settings.
D. Peak flow meter: A peak flow meter is more commonly used in asthma to monitor airway obstruction. In CF, lung function is better assessed with spirometry rather than peak expiratory flow, making this device less useful for routine home monitoring.
Correct Answer is C
Explanation
A. "Your provider would not prescribe this treatment if it weren't necessary.": While the provider recommends treatment based on medical necessity, the decision to continue or discontinue chemotherapy ultimately lies with the client. This response does not acknowledge the client’s autonomy.
B. "Chemotherapy is your best chance for survival.": This response focuses on treatment efficacy rather than addressing the client's emotional and personal concerns. It may also create pressure rather than supporting the client’s decision-making process.
C. "It is your decision whether to continue chemotherapy.": This response is appropriate as it acknowledges the client’s autonomy and right to make healthcare decisions. It validates the client’s concerns while offering support without imposing an opinion.
D. "Why don't you want to continue treatment?": Asking "why" may make the client feel defensive or pressured to justify their decision. A more open-ended approach, such as "Can you tell me more about your concerns?" would be a better way to explore the client’s feelings.
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