A nurse is caring for a client

Exhibits

A nurse is reviewing the client's electronic medical record. Which of the following findings requires follow-up?

Select all that apply.

Potassium level.

Temperature.

WBC count.

Breath sounds.

Blood pressure.

Answer and Explanation

Correct Answer : B,C,D

B, C, and D. These findings require follow-up because they indicate possible complications of chemotherapy, such as infection, low blood cell counts, and lung damage.

Choice B is correct because a temperature of 38.6° C (101.5° F) is a sign of fever, which can indicate an infection. Chemotherapy can weaken the immune system and make the client more prone to infections.

Choice C is correct because a WBC count of 3,800/mm3 is below the normal range of 5,000 to 10,000/mm3 and indicates leukopenia, a condition of low white blood cells. Chemotherapy can cause leukopenia by damaging the bone marrow where blood cells are produced.

Choice D is correct because crackles heard at the bases of the lungs are abnormal breath sounds that can indicate fluid accumulation or inflammation in the lungs. Chemotherapy can cause lung damage by affecting the cells that line the airways or by triggering an immune response.

Choice A is wrong because a potassium level of 3.6 mEq/L is within the normal range of 3.5 to 5 mEq/L and does not require follow-up.

Choice E is wrong because a blood pressure of 114/56 mm Hg is within the normal range of less than 120/80 mm Hg and does not require follow-up.

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Correct Answer is D

Explanation

This is because after puncturing the skin and the vein, the nurse needs to advance the catheter into the vein with the finger hub to ensure proper placement and prevent complications such as infiltration or phlebitis.

Choice A is wrong because flushing the catheter with saline should be done after securing the catheter to the skin with a transparent dressing and attaching a primed piece of extension tubing to the catheter.

Choice B is wrong because retracting the stylet should be done after advancing the catheter into the vein and releasing the tourniquet from the client’s arm.

Choice C is wrong because releasing the tourniquet should be done after advancing the catheter into the vein and before retracting the stylet.

A. Area of trauma. B. Sacrum. C. Shoulders. D. Palms of the hands.

Correct Answer is D

Explanation

Cyanosis is a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. It is more difficult to detect in people who have dark skin, so the nurse should look for cyanosis in areas where the skin is thinner and the blood supply is richer, such as the palms of the hands, the lips, the gums, and around the eyes.
These areas are less affected by melanin, the pigment that gives skin its color.

Choice A is wrong because an area of trauma may have bruising or inflammation that can mask cyanosis.
Choice B is wrong because the sacrum is not a good site to assess for cyanosis in any skin tone, as it is prone to pressure ulcers and poor circulation.
Choice C is wrong because the shoulders are not a mucous membrane and may have more melanin than other areas of the body.

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states. "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says. "Why don't you just leave me? I am of no use.”

A nurse is caring for a client Exhibits A nurse is reviewing the client's electronic medical record. Which of the following findings requires follow-up? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a prescription for a peripheral IV catheter. After puncturing the skin with the vascular access device and noting a blood return in the flashback chamber, which of the following actions should the nurse perform next?

Correct Answer is D

Explanation

A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client’s body should the nurse observe to assess for cyanosis?

Correct Answer is D

Explanation

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A nurse is caring for a client

Exhibits

A nurse is reviewing the client's electronic medical record. Which of the following findings requires follow-up?

Select all that apply.