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A nurse is caring for a 44-year-old client who was admitted with an elevated temperature and abdominal pain.
Exhibits

Select the top 4 client findings that requires immediate follow up.

Potassium 7.0 mEq/L (3.5 to 5 mEq/L)

WBC count 17,000/mm3 (Normal Finding: 5,000 to 10,000/mm3)

Crackles throughout lungs

Creatinine 3.0 mg/dL (0.5 to 1.3 mg/dL)

Abdomen rigid with decreased bowel sounds

Glucose 250 mg/dL

No dialysis for 24 hr

Hemoglobin 10 g/dL (12 to 18 g/dL) Nausea

Answer and Explanation

Correct Answer : A,B,C,H

A. Potassium 7.0 mEq/L (3.5 to 5 mEq/L): Elevated potassium levels (hyperkalemia) can cause life-threatening cardiac arrhythmias and are especially concerning in clients with chronic kidney disease who are at risk of renal complications. Immediate follow-up is crucial to prevent severe cardiac effects.

B. WBC count 17,000/mm³ (Normal Finding: 5,000 to 10,000/mm³): An elevated WBC count indicates an infection or inflammation, which is concerning given the client’s symptoms and temperature. This finding requires immediate follow-up to address potential infection.

C. Crackles throughout lungs: Crackles may indicate fluid overload or pulmonary edema, particularly in clients with chronic kidney disease. This could be a sign of worsening renal function or heart failure, which requires prompt attention.

H. No dialysis for 24 hr: Missing dialysis sessions in a client with stage IV chronic kidney disease can lead to dangerous fluid and electrolyte imbalances. This finding requires immediate action to prevent complications related to renal failure.

Explanation of Incorrect Options:

E. Creatinine 3.0 mg/dL (0.5 to 1.3 mg/dL): While elevated creatinine levels are concerning, the client’s history of chronic kidney disease means this level is expected to be higher. However, it is not as immediately critical as the other findings.

F. Abdomen rigid with decreased bowel sounds: This may suggest abdominal complications but is not as immediately critical as issues related to hyperkalemia or infection.

G. Glucose 250 mg/dL: Elevated glucose levels are concerning but less immediately critical compared to severe electrolyte imbalances and potential infections.

H. Hemoglobin 10 g/dL (12 to 18 g/dL): Anemia is a concern but is not as urgent as the immediate risks posed by elevated potassium, signs of infection, or missed dialysis.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Differences in upper and lower lung sounds are not indicative of atrial fibrillation but may suggest other conditions such as fluid accumulation or pneumonia.
B. A difference between apical and radial pulses, known as pulse deficit, can indicate atrial fibrillation due to the irregular and often rapid heartbeat that may not always produce a palpable radial pulse.
C. Differences between oral and axillary temperatures are not relevant to the assessment of atrial fibrillation but could indicate issues with measurement accuracy.
D. Different blood pressures in the upper limbs might suggest vascular issues but are not specific indicators of atrial fibrillation.

A. You may donate blood 6 months after completing the medication regimen. B. Rest frequently throughout the day. C. Consume a high-protein diet. D. Take acetaminophen every 4 hr, as needed, for discomfort.

Correct Answer is B

Explanation

A. Clients with hepatitis B should never donate blood, even after completing treatment, as they can remain carriers of the virus.
B. Resting frequently is essential for clients with hepatitis B as it helps the body recover and conserve energy during the healing process.
C. A high-protein diet is not recommended for hepatitis B patients; a balanced diet with adequate calories and nutrients is more appropriate to support liver health.
D. Acetaminophen is metabolized by the liver and should be used cautiously or avoided in clients with hepatitis B to prevent further liver damage.

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A nurse is caring for a 44-year-old client who was admitted with an elevated temperature and abdominal pain. Exhibits Select the top 4 client findings that requires immediate follow up.

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A nurse is caring for a 44-year-old client who was admitted with an elevated temperature and abdominal pain.
Exhibits

Select the top 4 client findings that requires immediate follow up.