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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

A.

Temperature 39.1° C (102.4° F)

B.

Blood pressure

C.

Skin turgor

D.

Temperature 39.2° C (102.5° F)

E.

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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Related Questions

Correct Answer is C

Explanation

Choice A reason:
A registered dietitian is not appropriate as he or she can provide nutritional assessment and guidance to ensure the client's dietary needs are met.
Choice B reason:
A speech-language pathologist is not appropriate because it is crucial for addressing communication and swallowing difficulties that can arise from a stroke.
Choice C reason:
Occupational therapy is the right choice. Clients who have had a stroke often experience difficulties with activities of daily living (ADLs) due to the physical and cognitive changes that can result from the stroke. Occupational therapists are specialized in helping individuals regain or develop the skills needed to perform daily activities and tasks. They can assist stroke survivors in regaining independence in activities such as dressing, grooming, bathing, and feeding.
Choice D reason:
A physical therapist can assist with mobility and improving physical functioning, but since the question specifically mentions assistance with morning ADLs, the occupational therapist is the most appropriate choice.

Correct Answer is C

Explanation

Choice A reason:
ALT is not primarily used to check kidney function. Kidney function is typically assessed through other tests, such as blood urea nitrogen (BUN) and creatinine levels.
Choice B reason:
ALT is not used to assess the risk of blood clots. It is specifically related to liver function.
Choice C reason:
Alanine aminotransferase (ALT) is an enzyme found primarily in the liver. An elevated ALT level in the blood can indicate potential liver damage or disease, so the ALT test is used to assess the function of the liver.
Choice D reason:
ALT is not a test to determine heart performance. Heart function is evaluated using tests such as electrocardiograms (ECGs) or cardiac enzymes.

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