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A nurse is assisting with the care of a client.

A nurse is reviewing the client's electronic medical record. Which of the following findings on day 7 require further action? Select all that apply.

Weight

Potassium

Pedal pulses

Temperature

Orientation

Chest x-ray

Urine output

Answer and Explanation

Correct Answer : A,C,F,G

Weight: The client has gained over 1 kg (about 2.2 lb) within a week, suggesting fluid retention. In combination with crackles, edema, and cardiomegaly, this weight gain indicates worsening heart failure and requires prompt intervention to manage fluid overload.
Potassium: A potassium level of 3.5 mEq/L is at the lower limit of normal. While it should be monitored, it does not independently demand immediate action unless it trends lower or the client shows symptoms of hypokalemia.
Pedal pulses: Pedal pulses have decreased from 2+ to 1+, and the extremities are now cool. These changes suggest compromised peripheral circulation, likely related to decreased cardiac output, and warrant further assessment and management.
Temperature: The client’s temperature is within the normal range. There are no signs of fever or hypothermia, so this finding does not require immediate action based on the current clinical data.
Orientation: The client remains alert and oriented, with no noted decline in mental status. Therefore, orientation findings are stable and do not necessitate further immediate intervention.
Chest x-ray: The presence of cardiomegaly on chest x-ray suggests worsening heart failure or fluid overload. This finding is significant and requires timely medical evaluation and management to prevent further cardiac decompensation.
Urine output: The client’s urine output has drastically decreased from 520 mL/hr to 160 mL in 8 hours, indicating impaired renal perfusion or acute kidney injury. This is a critical finding and requires immediate provider notification and intervention.

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Correct Answer is A

Explanation

A: Image A shows an injection being prepared at the deltoid muscle, which is the correct site and technique for administering the tetanus and diphtheria (Td) vaccine. The Td vaccine should be given intramuscularly, typically into the deltoid muscle of the upper arm in adults, using a 90-degree angle to ensure proper muscle penetration.

B: Image B shows an injection technique appropriate for intradermal or possibly subcutaneous injection, indicated by the shallow angle of insertion into the skin. This method is not correct for a Td vaccine, which requires intramuscular administration for proper absorption and effectiveness.

A. Allergy to penicillins B. Allergy to macrolides C. Allergy to sulfonamides D. Allergy to tetracyclines

Correct Answer is B

Explanation

A. Allergy to penicillins: Penicillin allergies are important when prescribing beta-lactam antibiotics like amoxicillin, but azithromycin is not a penicillin; it belongs to the macrolide class, so this allergy is not directly relevant.

B. Allergy to macrolides: Azithromycin is a macrolide antibiotic. An allergy to macrolides must be reported immediately because administering azithromycin could trigger an allergic reaction, which could be serious or life-threatening.

C. Allergy to sulfonamides: Sulfonamide allergies are relevant when prescribing medications like sulfamethoxazole-trimethoprim, but azithromycin does not belong to the sulfonamide class.

D. Allergy to tetracyclines: Tetracyclines are a different class of antibiotics, used for infections such as acne or certain respiratory infections. An allergy to tetracyclines is not a concern when administering azithromycin.

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A nurse is assisting with the care of a client. A nurse is reviewing the client's electronic medical record. Which of the following findings on day 7 require further action? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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A nurse is assisting with the care of a client.

A nurse is reviewing the client's electronic medical record. Which of the following findings on day 7 require further action? Select all that apply.