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 ["C","E"]
Explanation
A. An increase in hemoglobin does not indicate infection; it may indicate dehydration or improved oxygenation.
B. The absence of ketones in urine is not related to infection status.
C. An increase in band neutrophils, known as a "left shift," is a sign of infection as the body releases immature neutrophils in response to infection.
D. A negative leukocyte esterase in urine indicates no presence of white blood cells in the urine, suggesting no urinary infection.
E. An elevated erythrocyte sedimentation rate (ESR) is a nonspecific marker of inflammation and can indicate infection or other inflammatory processes.
Correct Answer is ["A","C","D","E"]
Explanation
A. A weakened gag reflex is a possible complication due to impaired nerve function, increasing the risk of aspiration.
B. Polyuria is not typically associated with cervical spinal cord injuries.
C. Hypotension may occur due to neurogenic shock from impaired autonomic function following a cervical spinal cord injury.
D. Hyperthermia can develop if the injury affects thermoregulatory control.
E. Absence of bowel sounds may indicate paralytic ileus, a common complication in clients with spinal cord injuries.
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