A nurse is admitting a client who reports tightness in their chest that radiates to left arm.
The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up.
Blood glucose level
Bowel sounds
Blood pressure
Pain level
Electrocardiogram findings
Lung sounds
Troponin T level
Correct Answer : C,D,E,G
A) The client’s blood glucose in this scenario is within the normal range.
B) The bowel sounds in this scenario are present in all the 4 quadrants which is normal.
C) The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.
D) The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.
E) The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.
F) The lungs are clear on auscultation of all the lobes which is normal.
G) The client's blood pressure is elevated at 164/80 mm Hg. Hypertension can exacerbate cardiac ischemia and increase the risk of complications. Therefore, monitoring and potential management of blood pressure are warranted.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Frequent diarrhea is not typically associated with cervical cancer.
B. Urinary hesitancy is more commonly associated with prostate issues in males rather than cervical cancer in females.
C. Unexplained weight gain is not typically a symptom of cervical cancer.
D. Painless vaginal bleeding, especially after intercourse or between periods, can be a sign of cervical cancer. It's essential for individuals to seek medical evaluation if they experience any abnormal bleeding.

Correct Answer is A
Explanation
A. The client's dyspnea and elevated blood pressure may indicate fluid volume overload. Slowing the infusion rate and notifying the provider are appropriate actions.
B. Lowering the head of the bed may help with dyspnea but does not address the underlying cause of fluid overload.
C. Administering corticosteroids is not indicated based on the client's symptoms and situation.
D. Changing the infusion to lactated Ringer's may be appropriate, but slowing the infusion rate and assessing the client further are the priority actions.
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