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A nurse is assisting with the care of a client

Exhibits
Select the 3 findings that require immediate follow-up.

A.

Pedal pulses

B.

Heart rate

C.

Oxygen saturation

D.

Blood pressure

E.

Abdominal dressing

F.

Breath sounds

Answer and Explanation

Correct Answer : B,D,E

Rationale:

• Heart rate of 110/min indicates tachycardia, which can be an early sign of hypovolemia, sepsis, or pain and should be followed up due to the recent report of a "popping" sound and increased drainage.
• Abdominal dressing now has a large amount of serosanguinous drainage, suggesting possible wound dehiscence or evisceration, which is a surgical emergency requiring prompt evaluation.
• Blood pressure of 98/50 mm Hg indicates hypotension, which, along with tachycardia and fever, suggests potential sepsis or internal fluid loss and needs immediate intervention.

• Pedal pulses are 2+, which is within normal limits and unchanged from Day 1, indicating adequate peripheral perfusion at present.
• Oxygen saturation at 95% on room air is within normal limits and not significantly changed from previous levels, requiring no urgent action.
• Breath sounds are still clear and present bilaterally, indicating no respiratory compromise or pulmonary complication at this time.


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Related Questions

Correct Answer is A

Explanation

Rationale:

A. Request the AP to provide a return demonstration of the task: Having the assistive personnel perform a return demonstration allows the nurse to directly observe their technique, ensuring the AP is competent and following proper procedures to prevent complications such as aspiration or infection.

B. Tell the AP to list the steps of the task: While verbalizing steps shows knowledge, it does not guarantee the AP can safely and effectively perform the feeding. Practical demonstration is necessary for skill verification.

C. Ask the family if the AP performed the task correctly: Family feedback may be subjective and is not a reliable method to assess the AP’s competency. The nurse should perform direct assessment.

D. Instruct the AP to report back once the task is complete: Reporting completion alone does not provide information about the quality or safety of the procedure. Direct observation is required to ensure proper technique.

Correct Answer is A

Explanation

Rationale:

A. Consult with a pharmacist about the medication: Consulting a pharmacist is the most appropriate action when a nurse is unfamiliar with a medication. Pharmacists are knowledgeable about drug indications, dosages, side effects, and interactions, making them a key resource for medication safety.

B. Ask the client about the medication: Clients may have some knowledge about their prescriptions, but they are not reliable sources for professional clinical decisions. Relying on client input when the nurse lacks knowledge could lead to unsafe medication administration.

C. Ask the charge nurse to administer the medication: Delegating the task does not resolve the knowledge gap. The nurse remains responsible for ensuring they understand any medication they are preparing, and should take steps to educate themselves rather than pass the task to another nurse.

D. Complete an incident report: An incident report is only warranted if a medication error or adverse event occurs. Being unfamiliar with a drug and seeking clarification is a preventive measure, not an incident requiring formal reporting.

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