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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 A

Explanation

A. Clients with Ménière's disease may experience dizziness and balance issues, so it is important to ensure safety by asking them to ring for assistance when moving around to prevent falls or injuries.
B. A prescription from the provider is not typically required for ambulation; instead, safety measures should be in place.
C. Allowing free movement without assistance may increase the risk of falls due to balance problems associated with Ménière's disease.
D. Strict bedrest is generally not necessary unless specifically indicated by the provider; assistance and safety measures are more appropriate.

A. The client complains of pain. B. The client develops a life-threatening situation. C. The client needs to have an x-ray of the femur performed. D. The client has to be repositioned in the bed.

Correct Answer is B

Explanation

A. Pain complaints are a common issue in skeletal traction and should be managed with appropriate interventions, but they do not warrant the removal of weights.
B. In a life-threatening situation, such as an acute deterioration in the client's condition, it is appropriate to remove the weights to address the emergency and stabilize the patient.
C. X-ray imaging should be coordinated with the traction team, but weights should not be removed solely for diagnostic procedures.
D. Repositioning in bed should be done carefully while maintaining the traction setup; removing weights is not typically required for this purpose.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

nurse is caring for the client who has Ménière's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs?

Correct Answer is B

Explanation

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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.