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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. Incorrect. While expressing empathy is important, the nurse should also provide practical information and support.
B. Incorrect. Delaying the discussion may leave the client feeling unheard and anxious about their upcoming chemotherapy.
C. Correct. This response acknowledges the client's concerns and provides a proactive solution to address the potential issue of hair loss. Offering information about head covering options demonstrates the nurse's support and willingness to help the client manage the physical and emotional impact of chemotherapy.
D. Incorrect. Dismissing the client's concern may contribute to their anxiety and apprehension about the chemotherapy process. It's important to address all aspects of the client's experience, including potential side effects like hair loss.

A. Initiate droplet precautions. B. Monitor the preschooler's urine for protein. C. Administer fluconazole to the preschooler. D. Request an x-ray of the preschooler's neck.

Correct Answer is A

Explanation

A. Correct. Respiratory syncytial virus (RSV. is primarily spread through respiratory droplets.
Initiating droplet precautions, which include wearing a mask and placing the client in a private room, is appropriate to prevent the spread of the virus.
B. Incorrect. Monitoring the preschooler's urine for protein is not relevant to the care of a client with RSV.
C. Incorrect. Fluconazole is an antifungal medication and is not indicated for the treatment of RSV.
D. Incorrect. Requesting an x-ray of the preschooler's neck is not relevant to the care of a client with RSV.

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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 caring for a client who is to begin chemotherapy. The client asks the nurse about managing hair loss. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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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.