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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. Incident report B. Nursing care plan C. Provider's progress notes D. Controlled substance inventory record

Correct Answer is A

Explanation

A. Correct. An incident report should be completed for any unintended event or situation that could have resulted or did result in harm to a patient. Administering the wrong dose of medication falls under this category.
B. Incorrect. The nursing care plan is a comprehensive outline of a patient's care needs and interventions and is not the appropriate place to document a medication error.
C. Incorrect. The provider's progress notes are meant to document the patient's condition, care, and progress, but they are not used to document medication errors.
D. Incorrect. The controlled substance inventory record is used to track the dispensing and administration of controlled substances, not to document medication errors.

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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 caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr. PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this client care incident?

Correct Answer is A

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.