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 C
Explanation
Choice A rationale:
Material safety data sheets (MSDS) primarily contain information related to hazardous chemicals and substances used in healthcare settings. While MSDS can be valuable for safety purposes, they do not provide comprehensive information on specimen collection protocols. Therefore, MSDS is not the most appropriate source for revising the specimen collection protocol.
Choice B rationale:
Client medical records are essential for individual patient care and documentation. However, they do not contain the information needed to revise the protocol for specimen collection on the unit. Medical records are specific to individual patient histories, diagnoses, and treatments, and do not address broader unit-wide protocols.
Choice C rationale:
Facility policy and procedures are the most appropriate source for retrieving information to revise the protocol for specimen collection on the unit. These policies and procedures are specifically designed to guide healthcare providers in delivering safe and effective care within the facility. They encompass standardized protocols for various clinical procedures, including specimen collection, making them the ideal source for the nurse's research.
Choice D rationale:
Evidence-based practice (EBP) involves using the best available research evidence, clinical expertise, and patient values to guide healthcare decisions. While EBP is crucial in healthcare, it is not the primary source for revising unit-specific protocols. EBP provides a broader framework for making clinical decisions but may not cover the specific policies and procedures unique to the facility.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.