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
The Correct Answer is ["A","D"]
Temperature 39.1° C (102.4° F), Temperature 39.2° C (102.5° F)
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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).
Correct Answer is B
Explanation
Choice A reason:
Performing percussion over the lower back: While percussion is part of the postural drainage technique, the specific areas to be percussed depend on the client's individualized care plan, which is based on the location of lung segments affected by cystic fibrosis. The nurse should follow the care plan and target the appropriate lung segments for percussion.
Choice B reason:
Covering the area of percussion with a towel is correct. When performing postural drainage with percussion and vibration for a client with cystic fibrosis, it is important to cover the area of percussion with a towel. This helps protect the client's skin and prevent discomfort or injury during the procedure. The towel acts as a barrier between the nurse's hand and the client's skin, allowing for effective percussion while minimizing friction and pressure
Choice Creason:
Scheduling postural drainage after meals: Postural drainage is ideally performed before meals or at least 1-2 hours after meals to avoid potential discomfort or vomiting due to the positioning and movement during the procedure.
Choice Dreason:
Instructing the client to exhale quickly during vibration: Vibration is typically performed during the client's exhalation phase, but the instruction should focus on slow, controlled exhalation rather than quick exhalation.
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