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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 C

Explanation

A. Potatoes are generally considered safe for toddlers to consume, as they are usually cooked until they are soft and easy to chew.
B. Oranges can be a choking hazard if not cut into small, manageable pieces, but they are less likely to cause choking than some other foods.
C. Correct. Grapes are small and round, making them a significant choking hazard for toddlers.
They can easily become lodged in a toddler's airway.
D. Corn kernels can also be a choking hazard for toddlers, especially if they are not chewed thoroughly or if the toddler eats them directly off the cob.

A. "You can safely take this medication if you become pregnant." B. "You can skip a dose of this medication if you are nauseated." C. "You should expect to have blood work every 6 months while taking this medication." D. "You might experience swollen gums while taking this medication."

Correct Answer is D

Explanation

A. Incorrect. Phenytoin is known to be a teratogenic medication, meaning it can cause birth defects. It is important for females of childbearing age to use effective contraception while taking phenytoin and to discuss pregnancy plans with their healthcare provider.
B. Incorrect. Skipping a dose of phenytoin can lead to changes in blood levels of the medication and may result in decreased seizure control. Nausea should be managed with the guidance of the healthcare provider.
C. Incorrect. Phenytoin can require regular monitoring of blood levels, but the frequency of blood work may vary based on the client's individual needs. Blood work is usually done more frequently than every 6 months, especially when starting or adjusting the medication.
D. Correct. Phenytoin can cause gingival hyperplasia, which leads to swollen and overgrown gums. This is a common side effect that clients should be informed about.

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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

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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.