A nurse is assisting with the care of a client
Select the 3 findings that require immediate follow-up.
Breath sounds at 1600
Temperature
Urticaria
Blood pressure at 1630
Report of dysphagia
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. An allergic reaction is an immune response to a medication, even if the patient has taken the medication before without issues. Symptoms like hives and itching are classic signs of an allergic reaction.
B. A side effect is an expected, often mild and predictable reaction to a medication, not typically involving an immune response and severe symptoms like hives.
C. A toxic effect refers to harmful effects from a medication overdose or accumulation in the body, not sudden onset after an appropriate dose.
D. An idiosyncratic reaction is an uncommon response not related to allergies or toxic effects, usually not presenting with hives and itching.
Correct Answer is B
Explanation
A. Repeating the prescription back to the provider ensures accuracy and is a best practice.
B. Telephone prescriptions should be transcribed into the appropriate medical record or order entry system, not just the nurse's notes. This ensures the prescription is documented correctly and can be acted upon by other healthcare team members.
C. Asking for clarification when the prescription is not understood is crucial to prevent errors.
D. Telephone prescriptions should be signed by the provider as soon as possible to ensure they are valid and have been accurately communicated.
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