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 ["A","B","C","D","E"]
Explanation
A) The client's pain level decreased from 7 to 5 after receiving nitroglycerin. This decrease indicates improvement in the client's condition.
B) The client’s respiratory rate decreased from 24/min to 22/min.
C) The client’s heart rate decreased from 120/min to 100/min.
D) Initially, the client's oxygen saturation was 93% on room air, which decreased to 89%. However, after receiving oxygen at 2 L/min via nasal cannula it improved to 92%.
E) The blood pressure decreased from 176/82 to 110/62.
F) Only one echocardiogram result showing myocardial infarction was provided.
G) Only one reading of I&O was provided showing an output of 32 mL, hence difficult to determine whether there was an improvement.
Correct Answer is B
Explanation
A) Nephrotic syndrome is not typically associated with decreased coagulation.
B) Proteinuria, or the presence of excessive protein in the urine, is a hallmark finding of nephrotic syndrome.
C) Nephrotic syndrome is actually associated with increased serum lipid levels.
D) Hyperalbuminemia is not typically associated with nephrotic syndrome; rather, hypoalbuminemia is more common due to loss of albumin in the urine.
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