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 B
Explanation
This is because epiglottitis is a life-threatening condition that can cause severe airway obstruction and respiratory distress in children. The nurse should monitor the child for signs of worsening breathing, such as stridor, cyanosis, restlessness, or drooling. The nurse should also be prepared to assist with intubation or tracheostomy if needed.
Choice A is wrong because assessing the child for frequent swallowing may increase the risk of vomiting and aspiration. Swallowing may also be difficult and painful for the child due to the inflammation of the epiglottis.
Choice C is wrong because suctioning the child’s oropharynx may cause more swelling and irritation of the epiglottis, or trigger a spasm that can close off the airway. The nurse should avoid any stimulation of the throat or mouth that may worsen the condition.
Choice D is wrong because administering pancreatic enzymes with meals is not relevant to epiglottitis. Pancreatic enzymes are used to treat cystic fibrosis, a genetic disorder that affects the lungs and digestive system. Epiglottitis is caused by a bacterial infection or an injury to the throat.
Correct Answer is A
Explanation
Respite care is a service that provides short-term inpatient care for terminally-ill patients at a professional care facility, such as a hospital, hospice inpatient care facility, or nursing home. It is meant to relieve caregiver stress and offer them rest and time away from caregiving duties. Respite care is covered by Medicare for up to five consecutive days and no more than one respite period in a single billing period.
The nurse should offer this option to the son who is experiencing sleep deprivation due to caring for his mother.
Choice B is wrong because it suggests that the son should rely on medication to cope with his situation, which may not be appropriate or effective.
Sleeping pills may have side effects or interactions with other drugs, and they do not address the underlying cause of the son’s stress and fatigue.
Choice C is wrong because it does not acknowledge the son’s need for support or assistance. It may sound like an empty compliment or a dismissal of the son’s concerns.
The nurse should express empathy and compassion, but also provide information and resources that can help the son.
Choice D is wrong because it does not offer any solution or guidance to the son.
It may also sound like a cliché or a generalization that does not reflect the son’s unique experience.
The nurse should avoid making assumptions or judgments about the son’s feelings or situation, and instead focus on his needs and preferences.
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