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A nurse is assisting in the care of a client.

Exhibits

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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Inform the charge nurse. The charge nurse should be notified when consent cannot be obtained so appropriate steps can be taken, such as rescheduling or involving the healthcare provider.
B. Send the client for the test with the unsigned form. Consent must be obtained before any invasive procedure. Proceeding without consent can result in legal and ethical consequences.
C. Obtain consent from a family member. A family member cannot give consent unless they hold legal power of attorney for healthcare decisions.
D. Wake the client and ask them to sign the form. Consent obtained under the influence of sedatives is not legally valid as it compromises the client's decision-making capacity.

A. Client care Kardex B. Standardized care plan C. I&O record D. Medication administration record

Correct Answer is A

Explanation

A. Client care Kardex: The Kardex provides a concise, comprehensive overview of the client's care needs, treatments, and status.
B. Standardized care plan: These are generalized and do not provide client-specific information.
C. I&O record: This record focuses solely on fluid intake and output and lacks comprehensive client details.
D. Medication administration record: This record provides details about medications but does not offer a complete picture of the client's care.

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A nurse is assisting in the care of a client. Exhibits 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.

Nursing Test Bank

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A nurse is assisting in the care of a client.

Exhibits

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.