A nurse is assisting in the care of a client.
The nurse is assisting in the care of the client. Which of the following findings should the nurse report to the provider?
Select the 5 findings the nurse should report.
Bowel pattern
Oxygen saturation
Respiratory assessment.
Temperature
Neurological status
X-ray results
Heart rate
Correct Answer : B,C,D,E,F
B.Oxygen saturation (92% on room air): A drop in oxygen saturation from 96% to 92% indicates impaired gas exchange, which may require oxygen therapy or further evaluation for respiratory compromise.
C. Respiratory assessment (crackles, chest tightness, productive cough with blood): Crackles and productive cough with hemoptysis are concerning for possible tuberculosis (TB) or another serious respiratory infection. Immediate notification ensures timely isolation and further diagnostic testing.
D. Temperature (38.8°C/101.8°F): The elevated temperature indicates a possible infection or worsening inflammatory process, especially concerning given the night sweats and recent international travel history.
E. Neurological status (lethargy): The progression from an alert state to lethargy suggests potential worsening of the client’s condition, possibly due to hypoxia, infection, or sepsis. Early identification is critical for preventing deterioration.
F. X-ray results (calcification in upper lobes): Calcifications in the upper lung lobes are characteristic of previous or latent TB infection. This, combined with the client’s current symptoms, requires prompt reporting to initiate appropriate infection control measures.
Findings Not Reported:
A.Bowel pattern (normoactive, last BM this morning): The bowel pattern is normal and not immediately relevant to the acute respiratory concerns.
G. Heart rate (114/min): Though elevated, the heart rate is likely a secondary response to the fever and respiratory compromise. While important to monitor, it does not warrant immediate provider notification independently.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
A. Applying a vacuum-assisted wound closure device on a client's pressure ulcer: This task requires clinical judgment and advanced training, which are appropriate for an RN.
B. Developing a plan of care for a newly admitted client: Creating care plans requires comprehensive assessment and clinical decision-making, which are within the RN's scope.
C. Preparing a teaching plan for a client who has a new prescription for insulin: Teaching requires advanced knowledge to assess learning needs and provide education.
D. Obtaining a client's post-void residual using a bladder scanner: This task is within the scope of practice for assistive personnel (AP) if trained.
E. Initiating the administration of a blood transfusion for a client: Blood transfusion initiation requires close monitoring and assessment for adverse reactions, which falls under the RN's scope.
Correct Answer is D
Explanation
A. Examine personal values: Understanding personal biases is important, but this is not the initial step in ethical decision-making.
B. Agree on a desired outcome: Reaching a consensus is essential but should come after gathering the necessary information.
C. Create a plan of action: Developing a plan is premature without gathering facts and understanding the situation.
D. Collect the relevant facts: Gathering all relevant information is the first step to understanding the ethical dilemma and determining an appropriate response.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.