A nurse is assisting in the care of a newly admitted client.
Which of the following findings should the nurse report immediately to the provider?
Select all that apply.
Heart rate
Pain
Cold, clammy skin
Mental confusion
Respiratory status
Blood pressure
Urine output
Temperature
Sodium level
Correct Answer : A,C,D,F,G,H
A. The heart rate increased from 90/min on Day 1 to 110/min on Day 2, indicating tachycardia. This can signify an underlying issue, such as hypovolemia or sepsis, especially given the other concerning findings.
B. While the pain level increased from 3/10 to 6/10, pain itself is subjective and should be monitored closely. It may require adjustment in pain management but is not immediately life-threatening compared to other findings.
D. The client's confusion and slow response can indicate a change in neurological status, possibly related to electrolyte imbalances, dehydration, or infection. This is a significant finding that requires immediate attention.
C. The client's skin changed from warm and dry to pale, cool, and clammy, suggesting possible shock or hypoperfusion. This is a critical sign that needs to be communicated to the provider.
E. The respiratory rate increased from 18/min to 22/min, indicating mild respiratory distress. While concerning, it does not represent an acute emergency compared to other findings and should be monitored.
F. The blood pressure dropped from 126/78 mm Hg on Day 1 to 80/60 mm Hg on Day 2, indicating possible hypotension. This change could signify worsening clinical status, potentially indicating shock or significant fluid loss.
G. The urine output decreased significantly from 400 mL over 8 hours to 100 mL over 6 hours, indicating possible acute kidney injury or dehydration.
H. The client’s temperature has increased from 37.2°C (99°F) to 38.4°C (101.1°F), indicating a possible infection or inflammatory response.
I. The sodium level remains within normal limits (144 mEq/L) and does not show significant changes. Therefore, it does not require immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Loose stools are not a typical finding related to external radiation for throat cancer.
B. Correct. Loss of taste (dysgeusia. is a common side effect of radiation therapy, particularly in the treatment area?
C. Bladder infection is not a typical finding related to external radiation for throat cancer.
D. Increased appetite is not a common finding related to radiation therapy; it's more commonly associated with certain medications or hormonal changes.
Correct Answer is D
Explanation
A. Cottage cheese is a dairy product that is not particularly high in fiber and might not effectively help with constipation.
B. Puffed rice cereal is often low in fiber and might not be the best choice to address constipation.
C. While tomato juice can have some benefits, it is not a high-fiber choice to help alleviate constipation.
D. Correct. Bran muffins are a good source of dietary fiber, which can help promote regular bowel movements and relieve constipation.
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