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A nurse is caring for a client who is admitted to the medical-surgical unit.

Exhibits

The nurse reviews the client's laboratory findings and vital signs. Select the 5 findings that require immediate follow-up.

Temperature

Blood pressure

Hemoglobin and hematocrit

WBC count

Stool results

Current medication

Heart rate

Respiratory rate

Answer and Explanation

Correct Answer : B,C,E,F,G

Rationale for correct choices:

Blood pressure: The client’s blood pressure is 90/50 mm Hg, indicating hypotension. This can signal volume depletion or active bleeding, which requires immediate assessment and intervention to prevent shock or organ hypoperfusion.
Hemoglobin and hematocrit: Hemoglobin of 9.1 g/dL and hematocrit of 27% indicate significant anemia, likely from gastrointestinal blood loss. Immediate follow-up is necessary to determine the source and provide interventions such as fluid resuscitation or transfusion.
Heart rate: The client’s heart rate is 118/min, demonstrating tachycardia. This may be compensatory for hypotension or blood loss, suggesting hemodynamic instability and requiring prompt monitoring and intervention.
Stool results: Positive hemoccult indicates gastrointestinal bleeding, which aligns with anemia and tachycardia. Identifying and managing the bleeding source is a priority to prevent further complications.
Current medication: The client takes high-dose ibuprofen (800 mg three times daily), a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs increase the risk for peptic ulcer disease and gastrointestinal bleeding, contributing to the client’s current presentation and requiring immediate provider notification.

Rationale for incorrect choices:

Temperature: The client’s temperature is 37.5° C (99.5° F), slightly elevated but not indicative of infection or immediate risk. Monitoring is appropriate but not urgent.
WBC count: WBC is 6,700/mm³, within normal limits, indicating no current infection or acute inflammatory response. This does not require immediate follow-up.
Respiratory rate: Respiratory rate is 18/min, within normal limits for an adult, and does not indicate acute respiratory distress. Immediate intervention is not necessary.

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Correct Answer is C

Explanation

Rationale:

A. Urine output 20 mL/hr: This urine output is below the recommended minimum of 30 mL/hr and may indicate magnesium toxicity or worsening renal perfusion. It is not a therapeutic effect and requires prompt evaluation.

B. BP 150/92 mm Hg: This blood pressure is still elevated and does not indicate optimal control of preeclampsia. Magnesium sulfate is given to prevent seizures, not primarily to lower blood pressure, so this is not a measure of therapeutic effect.

C. Absence of eclampsia: Magnesium sulfate is administered in preeclampsia to prevent the onset of eclampsia (seizures). The absence of seizure activity indicates that the medication is having its intended therapeutic effect.

D. FHR 116/min: This fetal heart rate is within the normal baseline range of 110–160/min, but it is not a direct therapeutic effect of magnesium sulfate. It is more a reflection of fetal well-being rather than the drug’s primary purpose.

A. Assess the client's breath sounds. B. Restrict the client's fluid intake. C. Perform chest percussion and vibration. D. Increase oxygen flow rate to 4 L/min. E. Instruct the client to perform diaphragmatic breathing. F. Place the client in a supine position.

Correct Answer is ["A","C","E"]

Explanation

A. Assess the client’s breath sounds: Auscultation helps determine how well interventions like albuterol and oxygen are working. Detecting changes such as worsening wheezes, crackles, or diminished sounds ensures early recognition of complications. This is vital given the client’s chronic smoking history and respiratory distress.

B. Restrict the client’s fluid intake: Adequate hydration thins mucus, making it easier to clear. Unless there is heart or kidney failure, fluids should be encouraged. Restricting intake could worsen secretion retention and impair gas exchange.

C. Perform chest percussion and vibration: These techniques loosen mucus and promote clearance in clients with COPD or chronic bronchitis. Because the client has a productive cough and abnormal lung sounds, this intervention supports better airway patency. It also works well alongside bronchodilators for improved breathing.

D. Increase oxygen flow rate to 4 L/min: In clients with chronic CO₂ retention, too much oxygen can suppress respiratory drive. The current prescription of 2 L/min should be maintained unless the provider reassesses and orders changes based on ABGs.

E. Instruct the client to perform diaphragmatic breathing: This method enhances airflow to the lower lungs, reduces accessory muscle use, and improves oxygen exchange. For a COPD client, it helps conserve energy and improve ventilation. Combined with pursed-lip breathing, it strengthens respiratory efficiency.

F. Place the client in a supine position: Lying flat limits lung expansion and can worsen dyspnea in clients with lung disease. An upright or high-Fowler’s position promotes maximal ventilation and better oxygenation.

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A nurse is caring for a client who is admitted to the medical-surgical unit. Exhibits The nurse reviews the client's laboratory findings and vital signs. Select the 5 findings that require immediate follow-up.

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A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. For which of the following therapeutic effects should the nurse monitor the client?

Correct Answer is C

Explanation

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Correct Answer is ["A","C","E"]

Explanation

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A nurse is caring for a client who is admitted to the medical-surgical unit.

Exhibits

The nurse reviews the client's laboratory findings and vital signs. Select the 5 findings that require immediate follow-up.