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 ["C","D","E","F"]
Explanation
A. Method is not one of the recognized 10 rights of safe medication administration. It is important to follow the correct method, but it is encompassed by the rights such as the right route and right time.
B. Unit is not part of the 10 rights of safe medication administration. Accurate dosage units are critical but are covered under the right dose and right medication.
C. The right medication ensures that the patient receives the correct drug, reducing the risk of adverse effects and therapeutic failures. Verifying the right medication is fundamental to safe medication administration practices.
D. The right evaluation involves monitoring the patient’s response to the medication to ensure it is effective and safe. This step helps in identifying any adverse reactions or the need for dosage adjustments.
E. The right assessment involves evaluating the patient’s condition before administering medication to determine if it is appropriate. It ensures that the medication is given safely, considering the patient’s current health status.
F. The right to client education involves informing the patient about the medication they are receiving, including its purpose, potential side effects, and any special instructions. Educating the patient promotes adherence and helps in the early identification of adverse effects.
Correct Answer is D
Explanation
A. Employee assistance programs (EAP) offer support services to employees but do not define the scope of nursing practice.
B. The US Food and Drug Administration (FDA) regulates food and drugs but does not define nursing practice.
C. The MedWatch program is a safety information and adverse event reporting system, not related to defining nursing scope.
D. State Nurse Practice Acts define the legal scope of nursing practice, including what tasks can be delegated to unlicensed personnel, ensuring safe and competent care.
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