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A nurse is assisting in the care of a client who presents to the emergency department.

Exhibits

A nurse is reviewing the client's medical record. Which of the following findings indicate the need for further evaluation?

Heart rate

Blood pressure

Temperature

Respiratory complaint

Oxygen saturation

Weight loss

Sputum characteristics

Travel history

Answer and Explanation

Correct Answer : C,D,F,G,H

A. a. Heart rate (98/min): A heart rate of 98/min is within the normal range for adults (60-100 bpm). This does not indicate an immediate need for further evaluation based on the provided data.

B. Blood pressure (112/88 mmHg): The blood pressure reading is within normal limits. This does not suggest an immediate concern.

C. Temperature: The client reports a low-grade fever (38.1°C or 100.5°F), which suggests an ongoing infection or inflammatory process. Further evaluation is necessary.

D. Respiratory complaint: A productive cough with blood-tinged sputum, especially in combination with symptoms such as fatigue, night sweats, and weight loss, is concerning and warrants further evaluation for possible serious conditions such as tuberculosis (TB) or other respiratory infections.

e. Oxygen saturation (98% on room air): The oxygen saturation is normal. This finding does not indicate an immediate need for further evaluation.

F.Weight loss: The client reports a significant weight loss of 26 kg (5 lbs) over the past week. Unintentional weight loss can be a concerning symptom and may indicate an underlying medical condition that requires further investigation.

G.Sputum characteristics: Blood-tinged sputum, especially with other symptoms like cough, fever, and night sweats, can be indicative of serious conditions such as TB or other respiratory infections and needs further evaluation.

H.Travel history: Recent travel to a region where certain infectious diseases are prevalent (such as TB) is a critical factor that requires further evaluation in the context of the client's symptoms.

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Correct Answer is B

Explanation

Applying pressure with gauze helps to control bleeding and promote clotting. The other statements are not accurate or appropriate for circumcision care: "I will apply antibiotic ointment to my baby's penis" is not recommended for Plastibell circumcision. The use of antibiotic ointment is not typically necessary or recommended unless specifically advised by the healthcare provider.

"I will wipe away yellow crusts that form around the incision" should not be done as it may disrupt the healing process. Yellow crusts are a normal part of the healing process and should be left undisturbed.

"I will make sure that my baby's diaper is applied snugly" is unrelated to circumcision care. While proper diapering is important for maintaining hygiene, it does not specifically address the care of the circumcision site.

A. Apply suction while inserting the catheter. B. Apply intermittent suction for 15 seconds. C. Wait 1 min between suctioning attempts. D. Insert the catheter 10 cm (4 in).

Correct Answer is C

Explanation

A.This is incorrect because suction should not be applied during the insertion of the catheter. Suctioning should only be applied while withdrawing the catheter to avoid causing trauma to the mucosa.

B. Suctioning should generally be performed for no longer than 10 seconds at a time to minimize the risk of complications such as hypoxia.

C.This response is correct because waiting approximately 1 minute between suctioning attempts allows the client time to recover and reoxygenate. This interval helps prevent hypoxia and mucosal damage, which are important considerations during the suctioning process.

D.In adults insert catheter approximately 16 cm (6.5 inches); in older children, 8– 12 cm (3–5 inches); in infants and young children, 4–7.5 cm (1.5–3 inches). Rule of thumb is to insert catheter distance from tip of nose (or mouth) to angle of mandible.

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A nurse is assisting in the care of a client who presents to the emergency department. Exhibits A nurse is reviewing the client's medical record. Which of the following findings indicate the need for further evaluation?

Nursing Test Bank

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A nurse is assisting in the care of a client who presents to the emergency department.

Exhibits

A nurse is reviewing the client's medical record. Which of the following findings indicate the need for further evaluation?