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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 C

Explanation

A. Handrails in the bathroom are a safety feature designed to prevent falls, which is beneficial for clients with decreased vision and other mobility issues.

B. Using a microwave for cooking is generally safe and convenient, especially for clients with decreased vision, as it reduces the need for handling hot pots and pans.

C. Scatter rugs can be a significant safety risk as they may cause tripping hazards, particularly for individuals with vision problems who may not see them clearly.

D. Electrical cords placed along the walls are less of a risk compared to scatter rugs. While they should be properly managed to avoid tripping hazards, they do not pose as immediate a risk as scattered rugs.

A. Medications will need to be taken for the rest of the client's life, even if the client feels better. B. A typical course of treatment involves 6 to 9 months of consistent medication use. C. Medications will need to be taken until the Mantoux test is negative. D. The client's family will also need to take medications to prevent infection.

Correct Answer is B

Explanation

TB medications are usually required for 6 to 9 months, not for the rest of the client’s life. The treatment duration is designed to ensure complete eradication of the bacteria.
B. A typical course of antitubercular medication involves 6 to 9 months of consistent use to fully treat the infection and prevent resistance.
C. The Mantoux test is used for screening and does not determine the duration of treatment. Medication should be continued as prescribed by the healthcare provider.
D. While family members may need to be screened and potentially treated if exposed, they do not routinely take medications solely to prevent infection unless specifically prescribed.

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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.