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 D
Explanation
A. A serum potassium level of 4.8 mEq/L is within the normal range and would not warrant withholding furosemide.
B. A serum sodium level of 140 mEq/L is within the normal range and would not warrant withholding furosemide.
C. An oxygen saturation of 95% is normal and would not warrant withholding furosemide.
D. A blood pressure of 80/40 mm/Hg is very low and administering furosemide, a diuretic, could further decrease blood pressure, posing a risk to the client. The nurse should withhold the medication and consult the provider.
Correct Answer is C
Explanation
A. Checking the pulse rate for 30 seconds and multiplying by 2 may not be accurate enough for a medication like digoxin, which requires precise monitoring.
B. Increasing sodium intake is not recommended for heart failure patients as it can worsen fluid retention and exacerbate symptoms.
C. Digoxin can cause bradycardia; therefore, it is crucial for clients to monitor their heart rate and contact their healthcare provider if it falls below 60/min to avoid adverse effects.
D. Taking digoxin with food can help with nausea but is not as critical as monitoring heart rate for potential toxicity.
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