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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.

A.

Weight

B.

Potassium

C.

Pedal pulses

D.

Temperature

E.

Orientation

F.

Chest x-ray

G.

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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Related Questions

Correct Answer is C

Explanation

A. "If I decide to get implants in my arm, I will get them replaced every 10 years.": Contraceptive implants, such as etonogestrel (Nexplanon), typically last about 3 to 5 years, not 10 years. Misunderstanding the replacement timeline could leave a client unprotected against pregnancy if not corrected.

B. "If I decide to get pregnant again, tubal reconstruction is a reliable option.": Tubal ligation is considered a permanent form of contraception. Although tubal reversal surgery exists, it is not always successful and is not a reliable or guaranteed method for restoring fertility.

C. "I get the birth control injection, I will need an injection 4 times a year.": The birth control injection, such as depot medroxyprogesterone acetate (Depo-Provera), is administered every 3 months, which totals about 4 injections per year. This statement shows a correct understanding of the injection schedule.

D. "If I get an IUD placed, I will not have menstrual bleeding.": Some types of IUDs, particularly hormonal IUDs, may reduce menstrual bleeding significantly, but complete absence of bleeding does not occur in all clients. Copper IUDs, in contrast, may actually increase menstrual bleeding and cramping.

Correct Answer is D

Explanation

A. Gloves: Gloves are important for contact precautions but are not sufficient protection against airborne infections like tuberculosis. Tuberculosis spreads through respiratory droplets that remain suspended in the air, requiring specialized respiratory protection.

B. Gown: A gown is generally used when there is a risk of direct contact with infectious material. While gowns are important for many isolation precautions, they do not protect against airborne transmission of tuberculosis.

C. Dosimeter badge: A dosimeter badge measures exposure to radiation, not infectious agents. It is used in environments with radiologic procedures and is unrelated to protecting against infectious diseases like tuberculosis.

D. N95 respirator: An N95 respirator is specifically designed to filter airborne particles, including Mycobacterium tuberculosis. It fits tightly around the face and provides the necessary protection against inhaling infectious airborne pathogens in the client’s environment.

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