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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

Answer and Explanation

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.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

After notifying the provider about the client's condition, the immediate actions should focus on managing the client's chest pain and potential cardiac event.

Administering oxygen at 2 L/min via nasal cannula helps ensure adequate oxygenation, while administering sublingual nitroglycerin helps alleviate chest pain and improve blood flow to the heart. The incorrect options do not address the immediate needs of a client experiencing chest pain and potential myocardial ischemia.

A. Irrigation of a wound with antibiotic solution B. Insertion of a nasogastric tube C. Placement of a central venous catheter D. Administration of an iron injection using Z-track technique

Correct Answer is C

Explanation

A. Incorrect. Irrigation of a wound with antibiotic solution typically does not require informed consent.
B. Incorrect. Insertion of a nasogastric tube does not usually require informed consent unless it involves specific risks or is part of a research protocol.
C. Correct. Placement of a central venous catheter is an invasive procedure that involves risks, and informed consent is usually required.
D. Incorrect. Administration of an iron injection using the Z-track technique is a routine procedure and does not usually require informed consent.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client. Exhibits Complete the following sentence by using the list of options. After notifying the provider, the nurse should and then

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?

Correct Answer is C

Explanation

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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.