A nurse is assisting with the care of a client

Exhibits

Select the 3 findings that require immediate follow-up.

Breath sounds at 1600

Temperature

Urticaria

Blood pressure at 1630

Report of dysphagia

Answer and Explanation

Correct Answer : C,D,E

A.   Bilateral breath sounds clear and present throughout at 1600 are normal findings and do not require immediate follow-up.
B.   The temperature at both 1600 (37.6°C) and 1630 (37.5°C) is slightly elevated but not critically high. It does not require immediate follow-up unless it worsens significantly or is accompanied by other concerning symptoms.
C.   Urticaria (hives) over the chest and trunk, along with itching and difficulty swallowing (dysphagia), are signs of an allergic reaction, which requires immediate follow-up and assessment.
D.   The blood pressure decreased to 78/52 mm Hg at 1630 from 110/58 mm Hg at 1600. This significant drop indicates hypotension and requires immediate follow-up.
E.   Difficulty swallowing (dysphagia) reported by the client suggests a potential airway compromise and requires immediate follow-up to assess the severity and intervene accordingly.

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Correct Answer is ["B","D"]

Explanation

A. Weekly laboratory tests for warfarin dosing are appropriate monitoring but do not indicate polypharmacy risk.
B. Using multiple pharmacies can increase the risk of drug interactions and duplications, indicating a higher risk of polypharmacy.
C. Allergies do not directly relate to polypharmacy.
D. Taking multiple medications for the same condition (e.g., hypertension) can increase the risk of drug interactions and adverse effects, indicating polypharmacy.
E. Having a family member assist with medication administration does not directly indicate polypharmacy risk.

A. Contact the provider to clarify the prescription. B. Interpret the prescription according to the client's medical history. C. Clarify the prescription with the family: D. Ask the pharmacist for clarification of the prescription.

Correct Answer is A

Explanation

A. Contacting the provider to clarify the prescription is the most direct and appropriate action to ensure accuracy and prevent medication errors.
B. Interpreting the prescription according to the client's medical history can lead to errors and is not a safe practice.
C. Clarifying the prescription with the family is not appropriate as they may not have the necessary knowledge or authority to interpret medical orders.
D. Asking the pharmacist for clarification can help, but the pharmacist may also have difficulty reading the handwriting. The most reliable approach is to directly contact the provider.

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A nurse is assisting with the care of a client Exhibits Select the 3 findings that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment finding indicates that the patient is at risk from polypharmacy? (Select all that apply.)?

Correct Answer is ["B","D"]

Explanation

A nurse is transcribing a client's medication prescriptions and is having difficulty reading the provider's handwriting. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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A nurse is assisting with the care of a client

Exhibits

Select the 3 findings that require immediate follow-up.