A nurse is caring for a client who is admitted to the medical-surgical unit.
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
Explanation
Rationale for Correct Choices:
- A change in mood: Isotretinoin can cause psychiatric effects such as depression, mood swings, and suicidal ideation. These symptoms may appear suddenly and progress rapidly without warning. Immediate reporting is necessary to ensure patient safety and initiate intervention.
- Visual disturbances: Isotretinoin may cause night blindness, blurred vision, or other changes in visual acuity. These effects can be irreversible if not addressed promptly by an ophthalmologic evaluation. Sudden onset visual changes require immediate discontinuation and assessment.
Rationale for Incorrect Choices:
- Nausea: This is a mild, nonspecific gastrointestinal symptom that may occur with many oral medications. It is not considered a hallmark of isotretinoin toxicity unless severe or persistent. Supportive measures are usually sufficient unless other symptoms emerge.
- The development of dry eyes: This occurs due to isotretinoin’s suppression of sebaceous and meibomian gland activity. It is a common, expected effect that can be relieved with lubricating eye drops. Urgent evaluation is not required unless accompanied by vision changes.
- Dry mouth: This is a frequent mucocutaneous effect related to reduced salivary gland activity during isotretinoin therapy. It does not indicate a dangerous reaction and is usually managed with hydration and sugar-free lozenges. Medical review is only needed if severe.
- Photosensitivity: Isotretinoin increases skin sensitivity to sunlight due to thinning of the epidermis. While uncomfortable, it is a predictable effect that can be prevented with sunscreen and protective clothing. It does not require stopping treatment unless severe burns occur.
- Dry skin and lips: This is the most common side effect, resulting from reduced sebaceous gland activity. It is usually managed with moisturizers and lip balm throughout therapy. It is not a sign of toxicity and rarely requires dose adjustment.
Correct Answer is ["140"]
Explanation
Calculation:
- Convert the client's current weight from kilograms (kg) to pounds (lbs).
Current weight (lbs) = Patient weight (kg) x Conversion factor (lbs/kg)
= 75 kg x 2.2 lbs/kg
= 165 lbs.
- Calculate the total weight loss over 25 weeks.
Total weight loss (lbs) = Weight loss per week (lbs) x Number of weeks
= 1 lb/week x 25 weeks
= 25 lbs.
- Calculate the expected goal weight in pounds (lbs).
Goal weight (lbs) = Current weight (lbs) - Total weight loss (lbs)
= 165 lbs - 25 lbs
= 140 lbs.
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