A nurse is caring for a client.
The nurse is assessing the client. Select the 4 findings that require immediate follow-up.
Heart rate
Hallucinations
Sleep pattern
Skin turgor
Hygiene
Correct Answer : A,B,C,D
A. Heart rate: A heart rate of 120/min is tachycardic and may indicate physiological stress, dehydration, or other medical complications. Immediate follow-up is necessary to assess underlying causes and prevent further cardiovascular compromise.
B. Hallucinations: The client is responding to unseen stimuli, which suggests possible psychosis or severe mania. Hallucinations pose a safety risk to the client and others and require urgent psychiatric and medical evaluation.
C. Sleep pattern: The client has not slept for 2 days, indicating severe sleep deprivation. Sleep loss can exacerbate agitation, impair judgment, and increase the risk of medical and psychiatric complications, making prompt intervention essential.
D. Skin turgor: Poor skin turgor indicates dehydration, which can lead to electrolyte imbalances, hypotension, and other acute complications. Immediate follow-up is needed to initiate fluid replacement and prevent further physiological deterioration.
E. Hygiene: Unclean hair and clothing reflect self-care deficits, but while important for overall well-being, hygiene issues do not require immediate intervention compared with vital signs, safety, and acute physiological concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I will complete my arm exercises four times a day.": Performing arm and shoulder exercises after a modified radical mastectomy helps maintain range of motion, prevent stiffness, and reduce the risk of lymphedema. Regular exercises multiple times a day reflect proper understanding of postoperative rehabilitation.
B. “I will have my drains removed 1 hour prior to going home.": Drain removal is based on the volume of drainage and physician assessment, not a set time before discharge. Premature removal can increase the risk of fluid accumulation and infection.
C. “I can begin to drive 24 hours after surgery.": Driving is usually not recommended until the client has regained adequate strength, range of motion, and is off strong pain medications, typically several days postoperatively. Doing so within 24 hours can be unsafe.
D. "I can shower within 48 hours of my surgery.": Showering is usually delayed until drains are in place and the incision is sufficiently healed, often following specific surgeon instructions. Showering too early can disrupt wound healing and increase infection risk.
Correct Answer is ["1"]
Explanation
Calculation:
- Identify the ordered dose and available concentration
Ordered Dose: 50 mcg
Available Concentration: 100 mcg/2 mL
- Calculate the volume to administer
Volume to administer = (Ordered Dose ÷ Concentration) × Volume of Concentration
Volume to administer = (50 ÷ 100) × 2
Volume to administer = 0.5 × 2
Volume to administer = 1 mL
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