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A nurse is admitting a client who reports tightness in their chest that radiates to left arm.

Exhibits

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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A) Padding the upper two side rails of the client's bed helps prevent injury during a seizure by reducing the risk of head trauma.
B) Maintaining peripheral IV access may not directly address the client's safety during a seizure.
C) Teaching assistive personnel to apply restraints is not appropriate for managing seizures and may not be indicated unless other safety measures have failed.
D) Keeping a padded tongue blade at the client's bedside is not necessary and may not be safe if the client experiences a seizure.

A. Alert and orientated x4 B. Heart and lung sounds clear C. Blood glucose 310 mg/dl. (74 to 106 mg/dL) D. Client is tolerating soft diet and oral fluids E. Bilateral pedal pulses 2+ F. Temperature 36.8° C (98.2° F) G. Pulse rate 84/min H. Respiratory rate 16/min I. Blood pressure 106/76 mm Hg J. Oxygen saturation 96% on room air

Correct Answer is ["C","E","G","I"]

Explanation

Rationale:

The client's condition shows signs of improvement as indicated by several findings. The blood glucose level has decreased from 468 mg/dL to 310 mg/dL, which, although still above the normal range, is a significant improvement. The pulse rate has normalized from 110/min to 84/min, and the blood pressure has improved from 96/65 mm Hg to 106/76 mm Hg, indicating better cardiovascular stability. The increase in bilateral pedal pulses from 1+ to 2+ suggests improved circulation.

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A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Exhibits The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up.

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Naxlex Comprehensive Predictor Exams

A nurse on the medical-surgical unit is caring for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is A

Explanation

Correct Answer is ["C","E","G","I"]

Explanation

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A nurse is admitting a client who reports tightness in their chest that radiates to left arm.

Exhibits

The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up.