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A nurse in a walk-in clinic is caring for a client.

Which of the following six findings should the nurse report to the provider? Select the 6 findings that require immediate follow-up.

1300:

Temperature 39.1° C (102.4° F)

Heart rate 115/min

Respiratory rate 30/min

Blood pressure 99/58 mm Hg

Oxygen saturation 93% on room air

1330:

Temperature 39.2° C (102.5° F)

Heart rate 118/min

Respiratory rate 28/min

Blood pressure 91/52 mm Hg

Oxygen saturation 95% on 2 L/min nasal cannula

Heart rate

Skin turgor

Temperature

Heart sounds

Blood pressure

COVID test results

Orientation

Lung sounds

Temperature 39.1° C (102.4° F)

Blood pressure

Skin turgor

Temperature 39.2° C (102.5° F)

COVID test results

Answer and Explanation

The Correct Answer is ["A","D"]

Temperature 39.1° C (102.4° F), Temperature 39.2° C (102.5° F)

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Correct Answer is A

Explanation

Choice A reason:
A. Place the tourniquet below the proposed insertion site.
When preparing to insert an IV catheter, placing the tourniquet below the proposed insertion site helps facilitate venous distension, making it easier to locate and access a suitable vein for catheter insertion.
Choice B reason:
Placing the extremity in a dependent position (lower than the heart) can increase venous pressure and make it more difficult to insert the catheter.
Choice C reason:
Choosing the most proximal site on the extremity is not always necessary or appropriate. Veins distal to the proposed insertion site should be considered first, as they tend to be smaller and less accessible.
Choice D reason:
Applying a cool compress is not typically done before IV catheter insertion. It might cause vasoconstriction and make it more difficult to access a suitable vein.

A. Percuss all four quadrants of the abdomen to measure sound quality. B. Provide adequate lighting to inspect the abdomen. C. Listen to the abdominal arteries using the bell of a stethoscope. D. Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen. E. Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen.

Correct Answer is B, C, E, D, A

Explanation

B. Provide adequate lighting to inspect the abdomen: Adequate lighting is important to ensure that the nurse can clearly see and assess the client's abdominal area. This step helps identify any visible abnormalities, such as skin changes, scars, masses, or distention.

C. Listen to the abdominal arteries using the bell of a stethoscope: Listening to the abdominal arteries helps the nurse assess blood flow and detect any abnormal vascular sounds, such as bruits or murmurs. This step provides information about vascular health and potential issues related to blood flow.

E. Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen: Palpating and locating the liver and spleen borders help assess the size and position of these organs. It can help identify hepatomegaly (enlarged liver) or splenomegaly (enlarged spleen), which could indicate various underlying conditions.

D.Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen: Palpating the abdomen for tenderness helps identify areas of discomfort or pain. It can provide information about potential inflammation, organ enlargement, or other sources of discomfort

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to insert an IV catheter for an adult client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is preparing to perform a physical assessment of a client's abdomen. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is B, C, E, D, A

Explanation

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