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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

A. Shakiness (tremors) is more commonly associated with hypoglycemia, where blood glucose levels drop too low. It is not typically a symptom of hyperglycemia. B. Cool skin is not a typical symptom of hyperglycemia. It is more commonly associated with poor peripheral circulation, which can occur in diabetes but is not specific to hyperglycemia itself. C. Thirst (polydipsia) is a common symptom of hyperglycemia in clients with diabetes mellitus. When blood glucose levels are elevated, the kidneys work to eliminate the excess glucose through urine, leading to increased urine production (polyuria). This increased urine production can result in dehydration, triggering the sensation of thirst as the body tries to maintain fluid balance. Thirst is a more common early indicator. D. Confusion can occur in severe cases of both hyperglycemia (diabetic ketoacidosis) and hypoglycemia. However, it is not specific enough on its own to indicate hyperglycemia without other symptoms like thirst and polyuria.

Correct Answer is B

Explanation

Choice A reason:

Sodium 140 mEq/L is incorrect because it falls within the normal range (135-145 mEq/L).

Choice B reason:

A potassium level of 5.8 mEq/L is appropriate because it is above the normal range (typically around 3.5-5.0 mEq/L). Elevated potassium levels, known as hyperkalaemia, can lead to serious cardiac disturbances, including arrhythmias or even cardiac arrest. It is important to notify the healthcare provider promptly so that appropriate interventions can be initiated to address the high potassium level.

Choice C reason:

Calcium 9.6 mg/dL is incorrect because it is within the normal range (8.5-10.5 mg/dL).

Choice D reason:

Magnesium 1.9 mEq/L is incorrect because it is within the normal range (1.5-2.5 mEq/L).

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