A nurse is caring for a client.
Vital Signs.
1600: Nurses' Notes.
Temperature 37.6°C (99.7°F). Blood pressure 110/58 mm Hg. Heart rate 72/min.
Respiratory rate 18/min.
Pulse oximetry 98% on room air.
1630: Temperature 37.5°C (99.5°F). Blood pressure 78/52 mm Hg. Heart rate 112/min.
Respiratory rate 26/min.
Pulse oximetry 92% on room air.
1600: Antibiotic administered as prescribed.
Bilateral breath sounds clear and present throughout.
1630: Client reports itching on the chest and has urticaria over the chest and trunk.
Client states they are having difficulty swallowing and feel as if there is a lump in their throat.
Bilateral breath sounds with scattered wheezing heard throughout.
Vital Signs.
Nurses' Notes.
Medication Administration Record.
Cefaclor 500 mg PO q8h.
Select the 3 findings that require immediate follow-up.
Breath sounds at 1600.
Temperature.
Urticaria.
Blood pressure at 1630.
Report of dysphagia.
Correct Answer : C,D,E
The correct answer is to select the following three findings that require immediate follow-up: C. Urticaria, D. Blood pressure at 1630, and E. Report of dysphagia.
Choice A rationale:
“Breath sounds at 1600.” The breath sounds at 1600 were clear and present throughout, which is a normal finding and does not require immediate follow-up.
Choice B rationale:
“Temperature.” The temperature readings at both 1600 and 1630 are slightly elevated but not critically high. This does not require immediate follow-up compared to the other findings.
Choice C rationale:
“Urticaria.” The presence of urticaria (hives) indicates an allergic reaction, which can potentially escalate to a more severe reaction such as anaphylaxis. Immediate follow-up is necessary to prevent further complications.
Choice D rationale:
“Blood pressure at 1630.” The blood pressure at 1630 is significantly lower (78/52 mm Hg) compared to the earlier reading (110/58 mm Hg). This hypotension could indicate a serious reaction to the medication or another underlying issue that requires prompt attention.
Choice E rationale:
“Report of dysphagia.” The client’s report of difficulty swallowing and feeling a lump in their throat is concerning for a potential airway obstruction or severe allergic reaction, such as anaphylaxis. This symptom requires immediate follow-up to ensure the client’s airway remains open and to provide necessary interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Encouraging family members to call the client is a valuable emotional and social support, but it may not be as effective in reducing social isolation for a client at the end of life. While communication with loved ones is important, it may not fully address the client's need for personal interaction.
Choice C rationale:
Instructing the client to join an online support group can be a useful intervention to reduce social isolation, especially in cases where physical interaction is limited. However, it may not be as effective for all clients, as comfort with technology and online groups can vary. Additionally, it should be one of several strategies used to address social isolation.
Choice D rationale:
Asking the client's friends to text the client is a positive gesture, but it may not be as effective as scheduling home visits with the client. Text messages may not provide the same level of personal interaction and emotional support that physical visits can offer.
Choice B rationale:
Scheduling home visits with the client is the most effective intervention to reduce social isolation in a client at the end of life. It allows for in-person interaction, emotional support, and the opportunity to address the client's physical and emotional needs directly. Face-to-face contact can significantly improve the client's sense of connectedness and reduce feelings of isolation.
Correct Answer is A
Explanation
Choice A rationale:
Skilled nursing is the most appropriate resource to anticipate for a postoperative client who needs physical therapy 2-3 times per day for two weeks. Skilled nursing facilities provide care from licensed nurses and therapists, making them well-suited for short-term rehabilitation and therapy services. These facilities offer a higher level of medical care compared to the other options, ensuring that the client's postoperative needs are adequately met.
Choice B rationale:
Assisted living is not the most suitable option for a postoperative client who requires physical therapy multiple times a day. Assisted living facilities are generally designed for individuals who need assistance with daily activities but do not require constant medical or therapeutic interventions.
Choice C rationale:
Long-term care is not the appropriate choice for a postoperative client with a two-week prescription for physical therapy. Long-term care facilities are designed for individuals who require ongoing, extended care, often due to chronic illnesses or disabilities. The client's condition is temporary, so long-term care is not warranted.
Choice D rationale:
Palliative care is intended for clients with serious, life-limiting illnesses, focusing on pain management and improving the quality of life. It is not suitable for a postoperative client who needs physical therapy for a limited duration. The primary goal of palliative care is different from the client's needs in this scenario.
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