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 D
Explanation
A. Incorrect. Tingling of the scalp is not a common adverse reaction following electroconvulsive therapy (ECT.
B. Incorrect. Voice alteration is not a common adverse reaction following ECT.
C. Incorrect. Neck pain is not a common adverse reaction following ECT.
D. Correct. Temporary memory loss is a common adverse reaction following ECT. Some clients may experience confusion and memory deficits immediately after the procedure, but these effects are typically temporary and resolve as the client recovers from the treatment.
Correct Answer is A
Explanation
A. Correct. Leaving steris-trips on until they fall off naturally promotes wound healing and reduces the risk of infection.
B. Incorrect. A high-fat diet is not recommended post-cholecystectomy; a low-fat diet is usually advised to prevent discomfort.
C. Incorrect. Diarrhea is not a common or expected outcome following laparoscopic cholecystectomy.
D. Incorrect. While some postoperative nausea might be expected, it should not persist for several days. Prolonged nausea may require medical attention.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.