A nurse is caring for a client in the emergency department (ED).
Select the 4 assessment findings on day 2 that require immediate follow-up.
Heart rate
Oxygen saturation
Edema
Temperature
Urine color
Pedal pulses
Correct Answer : A,C,E,F
A. Heart rate: The increased heart rate (108/min) may indicate a developing complication such as hypovolemia or pain. This requires monitoring as it could signal deteriorating status.
B. Oxygen saturation: The SpO₂ level is stable at 96%, which is within an acceptable range and does not indicate an immediate concern.
C. Edema: The increase in sacral and iliac region edema (2+) from day 1 to day 2 suggests worsening swelling and possible fluid accumulation, which could be affecting blood flow and leading to circulatory issues.
D. Temperature: The temperature remains within a normal range, so it does not require immediate intervention.
E. Urine color: Dark, reddish-brown urine suggests possible bleeding or rhabdomyolysis, both of which require immediate follow-up to prevent further complications and assess kidney function.
F. Pedal pulses: The change to 1+ pedal pulses bilaterally and the delayed capillary refill time (6 seconds) indicate reduced perfusion to the lower extremities, which may suggest compromised circulation or increased edema affecting blood flow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Obtaining a dietary history is relevant for ongoing management but is not the initial priority.
B. Reviewing electrolyte values is essential because exacerbations of ulcerative colitis can lead to severe fluid and electrolyte imbalances, which need prompt correction.
C. Investigating emotional concerns is important but does not take precedence over addressing potential electrolyte imbalances that can be life-threatening.
D. Checking perianal skin integrity is relevant for comfort but is not the priority in stabilizing the client during an acute exacerbation.
Correct Answer is C
Explanation
A. Constipation is not a common side effect of donepezil; gastrointestinal effects are usually limited to diarrhea, nausea, and vomiting.
B. Donepezil is typically administered at bedtime to reduce the risk of daytime side effects like dizziness.
C. Syncope (fainting) can occur as a side effect of donepezil, especially when changing positions, due to its effects on heart rate.
D. Donepezil may cause bradycardia (slow heart rate), not tachycardia.
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