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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. An elevated WBC count with increased immature neutrophils (bands) indicates an acute infectious process. The presence of bands suggests that the body is responding to an infection and producing neutrophils rapidly to fight off the infection.

B. An allergic reaction is more commonly associated with an elevated eosinophil count rather than neutrophils. The laboratory findings described do not support an allergic reaction.

C. Neutropenia is characterized by a low neutrophil count, not an elevated one. The presence of increased immature neutrophils suggests an infection rather than neutropenia.

D. A resolving inflammatory process would typically show a decrease in immature neutrophils (bands) and a normalization of the WBC count, rather than an elevated WBC with increased bands.

A. The client's bladder becomes distended. B. The client's blood pressure becomes elevated. C. The client states having nasal congestion. D. The client states having a severe headache.

Correct Answer is A

Explanation

A. Bladder distension is a common trigger for autonomic dysreflexia in individuals with spinal cord injuries above T-6. It is crucial to manage bladder function to prevent this potentially life-threatening condition.

B. Elevated blood pressure is a sign of autonomic dysreflexia rather than a predisposing factor. Identifying the trigger, such as bladder distension, is essential before addressing the elevated blood pressure.

C. Nasal congestion is not typically associated with autonomic dysreflexia. While it might be uncomfortable, it is not a common trigger for this condition.

D. A severe headache can be a symptom of autonomic dysreflexia, but identifying the underlying cause or trigger, such as bladder distension, is essential for proper management.

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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

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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.