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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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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. Temperature B. Blood pressure C. Pain level D. Adalimumab frequency E. Heart sounds F. WBC count G. Urinalysis H. Hgb & Hct

Correct Answer is ["A","B","C","F","G"]

Explanation

A. Temperature: The client has a fever (39.3°C/102.8°F) indicating a potential infection or inflammatory process. This requires immediate follow-up to address the underlying cause of the fever.

B. Blood pressure: The client’s blood pressure is low (84/58 mm Hg on admission and 88/58 mm Hg current), suggesting possible shock or severe dehydration. This finding requires immediate assessment and intervention.

C. Pain level: The client reports increasing back and suprapubic pain, which could be related to a urinary tract infection or other serious condition. Addressing pain and its cause is critical.

D. Adalimumab frequency: The current medication schedule for Adalimumab is less urgent compared to the acute findings. The frequency of this medication does not require immediate follow-up in this context.

E. Heart sounds: No dysrhythmias were noted on the cardiac monitor, so this finding does not require immediate follow-up at this time.

F. WBC count: The WBC count is elevated with leucocyte esterase positive, indicating an infection. This warrants immediate attention to diagnose and treat the infection.

G. Urinalysis: The urinalysis shows cloudy appearance, foul odor, and alkaline pH with positive leucocyte esterase, suggesting a urinary tract infection. This requires immediate follow-up to start appropriate treatment.

H. Hgb & Hct: While important, these values are not provided in the current context. The immediate concerns are more focused on the acute symptoms and signs provided.

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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.

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.