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 ["B","C","D"]
Explanation
A. Place throw rugs on uncarpeted floors in the client's home. Throw rugs are a tripping hazard and should be removed or secured.
B. Ensure the client wears non-skid slippers when walking around the house: Non-skid slippers provide traction and reduce the risk of slipping.
C. Encourage an annual review of the medications the client is taking. Many medications can cause dizziness or sedation, increasing fall risk, so regular medication reviews are essential.
D. Install a raised toilet seat in the client's bathroom. A raised toilet seat makes it easier for older adults to use the toilet and reduces the risk of falls when standing or sitting.
E. Attach full-length side rails to the client's bed. Full-length side rails can increase the risk of injury if the client attempts to climb over them. Half-rails may be safer.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
- Malpractice: This refers to professional negligence when a healthcare provider fails to meet the standard of care. Floating to an unfamiliar unit increases the risk of errors, potentially leading to malpractice claims.
- Insufficient training: The nurse typically lacks adequate orientation and experience with procedures specific to the adult medical-surgical unit, placing clients at risk.
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.