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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 A

Explanation

Explanation:

A nasal cannula is a device used to deliver supplemental oxygen to a client. It consists of two prongs that are inserted into the client's nostrils and connected to an oxygen source. The nasal cannula is commonly used for low-flow oxygen delivery at a rate of 1 to 2 liters per minute (L/min).

The other options mentioned are not necessary supplies for the client upon discharge:

B- Petroleum jelly is not directly related to oxygen therapy and is not a required supply for the client. It is a common topical ointment used for various purposes such as moisturizing the skin or protecting the lips, but it is not specifically needed for oxygen administration.

C- An oxygen mask is an alternative device for oxygen delivery but is not typically used at a flow rate of 1 to 2 L/min. Oxygen masks are usually employed for higher flow rates or in specific clinical situations that require a different oxygen delivery method.

D- A reservoir bag is a component of some oxygen delivery systems, such as a non-rebreather mask or a bag-valve-mask device. However, at a flow rate of 1 to 2 L/min, a reservoir bag is not typically used. It is more commonly utilized in situations where higher oxygen concentrations or higher flow rates are required.

A. "Why don't you want to learn how to give yourself your medication?" B. "You will suffer serious health issues if you don't take your medication." C. "I'd like to hear your thoughts about giving yourself this medication." D. "Have you considered how your decision to refuse medication will affect your family?"

Correct Answer is C

Explanation

This response allows the nurse to express genuine interest in the client's perspective and opens up a dialogue to understand the client's concerns or reasons for refusing to learn how to self-administer insulin. It provides an opportunity for the client to express their fears, doubts, or any barriers they may have. By actively listening to the client, the nurse can better address their concerns and provide appropriate education and support tailored to their individual needs.

The other options may come across as confrontational, judgmental, or unhelpful in establishing a therapeutic relationship with the client. It is important for the nurse to approach the situation with empathy, respect, and a non-judgmental attitude to foster effective communication and promote the client's engagement in their own care.

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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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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?