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 A
Explanation
A. The right hemisphere controls judgment, reasoning, and impulse control, so clients may exhibit impulsive behaviors after a right-sided stroke.
B. Deficits in the right visual field would occur with a left hemisphere stroke, not a right hemisphere stroke.
C. Difficulty discriminating words and letters is typically associated with left hemisphere damage.
D. Motor retardation is not a specific finding associated with right hemisphere strokes; these often involve impulsive behavior and left-sided neglect.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"D"},"E":{"answers":"A"}}
Explanation
Platelet count: Low platelets (135,000/mm³) increase bleeding risk as they are essential for clot formation.
Hemoglobin: A hemoglobin level within the low normal range could increase the risk of hypoxemia, particularly in the perioperative period when oxygen demand may be higher.
INR: Elevated INR (1.5) indicates increased bleeding risk due to prolonged clotting time.
Atrial fibrillation: Increases the risk of DVT due to irregular heart rhythms, which can lead to blood pooling and clot formation.
RBC count: A low RBC count contributes to the risk of hypoxemia as there are fewer red blood cells available to transport oxygen.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.