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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

Before any invasive procedure, it is essential to ensure that the client has given informed consent. Informed consent involves providing the client with detailed information about the procedure, its risks and benefits, and alternatives. The client should have the opportunity to ask questions and fully understand the procedure before giving consent.

Oral contrast solutions are typically used for imaging procedures such as CT scans or X-rays, not for esophagogastroduodenoscopy. This procedure involves the insertion of a flexible tube with a camera into the esophagus, stomach, and duodenum to visualize the upper gastrointestinal tract.

While it is important to provide the client with information about the duration of the procedure, stating a specific time frame may not be accurate or helpful. The duration of an esophagogastroduodenoscopy can vary depending on factors such as the complexity of the procedure and the client's individual circumstances.

Having a full bladder is not necessary for an esophagogastroduodenoscopy procedure. This requirement may be relevant for other procedures, such as pelvic ultrasound, but it is not applicable in this case.

A. Obtain a complete blood count. B. Prepare client for insertion of 18-gauge peripheral IV prior to surgery. C. Administer Rh, D immune globulin prior to surgery. D. Explain the surgical procedure to the client. E. Verify consent form is signed by the client. F. Assist with administration of AB positive blood products if needed. G. Remind client to be NPO prior to surgery.

Correct Answer is ["A","B","C","E","G"]

Explanation

Based on the given information, the nurse should take the following actions in preparation for surgery:

Obtain a complete blood count: This is important to assess the client's hemoglobin, hematocrit, and other blood parameters before surgery.
Prepare the client for insertion of an 18-gauge peripheral IV prior to surgery: Adequate IV access is necessary for the administration of fluids and medications during and after surgery.
Administer Rh, D immune globulin prior to surgery: This action is indicated if the client is Rh-negative and there is a possibility of fetal-maternal blood mixing during the termination of pregnancy. Rh, D immune globulin is given to prevent sensitization to Rh-positive blood.
Verify consent form is signed by the client: Ensuring that the client has provided informed consent is essential before proceeding with any surgical intervention.
Remind the client to be NPO (nothing by mouth) prior to surgery: It is important for the client to have an empty stomach to reduce the risk of aspiration during anesthesia.

The following actions are not indicated based on the given information:

Explaining the surgical procedure to the client: Although it is important for the client to have an understanding of the procedure, this is typically done by the surgeon rather than the nurse.
Assisting with administration of AB positive blood products if needed: There is no indication of the need for blood products based on the information provided. Blood product administration would be determined based on the client's specific condition and surgical requirements.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure?

Correct Answer is B

Explanation

Exhibits The nurse is preparing the client for surgery. Which of the following actions should the nurse take? Select all that apply

Correct Answer is ["A","B","C","E","G"]

Explanation

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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?