A nurse is caring for a client
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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A client who is ambulatory and receiving oxygen should be evacuated first during a fire because they are at risk of fire and explosion from the oxygen source. The nurse should instruct the staff to turn off the oxygen supply, remove the oxygen device from the client, and assist them to walk out of the building using the nearest exit.
Choice B is wrong because a client who uses a wheelchair and is confused is not in immediate danger from the fire. They can be evacuated using a swing carry or an extremity carry by two staff members after the clients who are more vulnerable are evacuated.
Choice C is wrong because a client who is bedridden and wears a hearing aid is not in immediate danger from the fire. They can be evacuated using a cradle drop by one staff member after the clients who are more vulnerable are evacuated.
Choice D is wrong because a client who has a fracture and is in balance suspension traction is not in immediate danger from the fire. They can be evacuated using a special device such as a sked or a sled by two or more staff members after the clients who are more vulnerable are evacuated.
Correct Answer is B,D,A,C
Explanation
B. Review the skill level and qualifications of each AP.
Before delegating tasks, the nurse should assess the skill level and qualifications of each AP to ensure they have the necessary knowledge and training to perform the assigned tasks safely and effectively.
D. Communicate appropriate tasks to the APs with specific expectations.
The nurse should clearly communicate the tasks to be delegated to each AP. This includes providing specific instructions, expectations, and any necessary information to ensure the APs understand what is expected of them and can perform the tasks correctly.
A. Monitor progress of task completion with each AP.
Once the tasks are assigned, the nurse should periodically check in with each AP to monitor the progress of task completion. This allows the nurse to provide support, answer questions, and ensure that tasks are being performed as expected.
C. Evaluate the APs' performance of each task.
After the tasks are completed, the nurse should evaluate the APs' performance of each task. This evaluation helps identify any areas for improvement, additional training needs, and overall competency of the APs.
Delegating tasks to assistive personnel is an essential aspect of nursing practice. Following this sequence of steps helps ensure that tasks are delegated appropriately and that the care provided is safe, efficient, and aligned with the APs' capabilities. Regular communication and feedback are essential to effective task delegation and teamwork within the healthcare setting.
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