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A nurse is caring for a client who is admitted to the medical-surgical unit. Client reports, "I'm bloated and my stomach hurts."

Exhibits

The nurse reviews the client's laboratory findings and vital signs.

Select the 5 findings that require immediate follow-up.

Heart rate.

Current medications.

Blood pressure.

Stool results.

Respiratory rate.

WBC count.

Temperature.

Hemoglobin and hematocrit.

Answer and Explanation

Correct Answer : A,B,C,D,H

A, B, C, D, and H. Here is why:.

A. Heart rate: The client’s heart rate is elevated at 118/min, which could indicate blood loss, dehydration, pain, anxiety, or infection. This finding requires immediate follow-up to assess the cause and intervene as needed.
B. Current medications: The client is taking ibuprofen 800 mg three times daily PRN for arthritis pain. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastric irritation, ulceration, and bleeding. This finding requires immediate follow-up to evaluate the client’s pain level, medication use, and possible alternatives to NSAIDs.
C. Blood pressure: The client’s blood pressure is low at 90/50 mm Hg, which could indicate hypovolemia, shock, or cardiac dysfunction. This finding requires immediate follow-up to monitor the client’s fluid status, perfusion, and organ function.
D. Stool results: The client’s stool tested positive for occult blood and H. pylori bacteria. Occult blood indicates gastrointestinal bleeding, which could be related to the client’s abdominal pain and weight loss. H. pylori is a common cause of peptic ulcer disease, which can also cause bleeding and pain. This finding requires immediate follow-up to confirm the diagnosis and initiate treatment with antibiotics and acid-suppressing drugs.

H. Hemoglobin and hematocrit: The client’s hemoglobin and hematocrit are low at 9.1 g/dL and 27%, respectively. These values indicate anemia, which could be caused by chronic blood loss, nutritional deficiency, or bone marrow suppression. This finding requires immediate follow-up to determine the etiology and severity of the anemia and provide appropriate therapy such as blood transfusion, iron supplementation, or erythropoietin.

The other findings are not as urgent as the ones above:.

E. Respiratory rate: The client’s respiratory rate is normal at 18/min. There is no evidence of respiratory distress or hypoxia.
F. WBC count: The client’s WBC count is normal at 6,700/mm3. There is no indication of infection or inflammation.
G. Temperature: The client’s temperature is slightly elevated at 37.5° C (99.5° F), but not enough to warrant immediate concern. It could be due to stress, dehydration, or a mild infection. The nurse should monitor the temperature trend and report any significant changes or signs of sepsis.

Nursing Test Bank

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Correct Answer is B

Explanation

The correct answer is B. Hip arthroplasty 1 week ago.

Alteplase is a drug that dissolves blood clots by converting plasminogen to plasmin. It can be used for acute ischemic stroke, but it has some contraindications that depend on the indication and the type of administration of the drug. Some common contraindications for alteplase are hypersensitivity, active internal bleeding, history of intracranial hemorrhage, bleeding disorders, and high blood pressure. Other contraindications may vary depending on the specific condition and the time window of treatment. Alteplase can cause serious or fatal bleeding as a side effect.

Choice A is wrong because family history of malignant hypertension is not an absolute contraindication for alteplase, although uncontrolled hypertension (>185 mmHg SBP or >110 mmHg DBP) is.

Choice C is wrong because chronic obstructive pulmonary disease is not a contraindication for alteplase, although it may increase the risk of pulmonary hemorrhage.

Choice D is wrong because acute renal failure 6 months ago is not a contraindication for alteplase, although current use of direct thrombin inhibitors or direct factor Xa inhibitors is.

Normal ranges for blood pressure are <120/80 mmHg for normal, 120-129/<80 mmHg for elevated, 130-139/80-89 mmHg for stage 1 hypertension, and ≥140/≥90 mmHg for stage 2 hypertension.

Normal ranges for platelet count are 150,000 to 450,000 platelets per microliter of blood.

Normal ranges for INR are 0.8 to 1.2 for people who are not taking blood thinners and 2 to 3 for people who are taking warfarin.

Normal ranges for aPTT are 25 to 35 seconds for people who are not taking blood thinners and 46 to 70 seconds for people who are taking heparin.

A. Cross the client’s arms across their chest. B. Place the client in a high-Fowler’s position C. Hold the client’s eyes shut for a few seconds. D. Remove the client’s dentures from their mouth

Correct Answer is C

Explanation

The correct answer is choice C. Holding the client’s eyes shut for a few seconds.

This is because the eyes of a deceased client do not close naturally and may remain open after death. Holding them shut for a few seconds helps to keep them closed and prevent drying of the corneas.

This also gives a more peaceful appearance to the client’s body for the family visit.

Choice A is wrong because crossing the client’s arms across their chest is not a standard postmortem care procedure. It may also interfere with the placement of identification tags on the wrists.

Choice B is wrong because placing the client in a high-Fowler’s position is not necessary or appropriate for postmortem care. The client should be placed in a supine position with the head of the bed elevated to prevent livor mortis (purple discoloration of the skin) on the face.

Choice D is wrong because removing the client’s dentures from their mouth is not recommended for postmortem care. The dentures should be left in place to maintain the shape of the face and prevent the jaw from dropping.

Normal ranges are not applicable for this question as it does not involve any physiological measurements.

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A nurse is caring for a client who is admitted to the medical-surgical unit. Client reports, "I'm bloated and my stomach hurts." Exhibits The nurse reviews the client's laboratory findings and vital signs. Select the 5 findings that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is reviewing the medical record of a client who is having an acute myocardial infarction. Which of the following findings places the client at risk if he receives alteplase?

Correct Answer is B

Explanation

A nurse is performing postmortem care for a recently deceased client prior to the client’s family visit. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

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A nurse is caring for a client who is admitted to the medical-surgical unit. Client reports, "I'm bloated and my stomach hurts."

Exhibits

The nurse reviews the client's laboratory findings and vital signs.

Select the 5 findings that require immediate follow-up.