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A nurse is caring for a client in a long-term care facility.

Exhibits
Which of the following assessment findings require follow-up by the nurse? Select all that apply.

Vocal quality

Blood pressure

Albumin

BMI

Dentition

Bowel pattern

Lung sounds

Temperature

Secretions

Posture

Answer and Explanation

Correct Answer : A,D,F,G,H,I,J

A. Vocal quality – The client’s voice is hoarse and weak on Day 30, which may indicate dehydration, malnutrition, or an underlying respiratory issue.

B. Blood pressure – The client's blood pressure has slightly decreased but remains within a normal range, so it does not require immediate follow-up.

C. Albumin – Serum albumin levels are still within normal range.

D. BMI – The drop from 20 to 19 suggests unintentional weight loss, which could indicate malnutrition, inadequate intake, or an underlying illness.

E. Dentition –No difficulty in chewing reported.

F. Bowel pattern – The client has constipation for three days, which may require intervention to prevent complications like fecal impaction or discomfort.

G. Lung sounds – Diminished breath sounds at the bases may indicate fluid accumulation, atelectasis, or respiratory infection, requiring further evaluation.

H. Temperature – The client’s fever (38.1°C/100.6°F) suggests a possible infection and requires monitoring for underlying illness.

I. Secretions – Thick oral secretions may indicate dehydration, poor oral hygiene, or a swallowing issue, requiring follow-up to prevent aspiration.

J. Posture – The client’s slumped posture and fatigue could indicate weakness, nutritional deficiencies, or an underlying neurological or musculoskeletal problem.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Apply firm, direct pressure to the catheter insertion site is the best first action because it directly addresses the immediate concern of bleeding, helping to prevent excessive blood loss and stabilize the client.

Assess vital signs and assess for signs of hypovolemia is the best next action, as the client's increasing heart rate and decreasing blood pressure suggest potential blood loss, which could lead to hypovolemic shock.

Incorrect answers;

Lowering the head of the bed and assessing circulation (B in i) is important but should follow bleeding control.

Increasing IV fluids (C in i) may be necessary but should be done based on provider orders after controlling bleeding.

Preparing for fluid resuscitation (B in ii) is relevant but is not the first step; monitoring vitals is a more immediate priority.

Notifying the provider (C in ii) is crucial but should occur after assessing the client's status to provide accurate information.

A. Bradypnea B. Restlessness C. Hypertension D. Tachycardia

Correct Answer is D

Explanation

A. Bradypnea: Bradypnea (slow breathing) is not a typical late sign of hypoxia. Instead, clients with worsening hypoxia often develop tachypnea (rapid breathing) as the body tries to compensate for low oxygen levels.

B. Restlessness: Restlessness is an early sign of hypoxia, not a late one. It occurs due to inadequate oxygenation of the brain, leading to agitation and confusion.

C. Hypertension: Hypertension can be an early response to hypoxia as the body attempts to increase oxygen delivery. However, as hypoxia progresses, blood pressure may drop due to worsening oxygen deprivation.

D. Tachycardia: Tachycardia (increased heart rate) is a late sign of hypoxia. The heart compensates for low oxygen levels by increasing cardiac output. However, if untreated, hypoxia can progress to bradycardia and cardiac arrest.

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A nurse is caring for a client in a long-term care facility. Exhibits Which of the following assessment findings require follow-up by the nurse? Select all that apply.

Nursing Test Bank

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

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A nurse is caring for a client in a long-term care facility.

Exhibits
Which of the following assessment findings require follow-up by the nurse? Select all that apply.