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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.

A.

Temperature

B.

Blood pressure

C.

Hemoglobin and hematocrit

D.

WBC count

E.

Stool results

F.

Current medication

G.

Heart rate

H.

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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Related Questions

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

Rationale for correct choices:

• Reye’s syndrome is a rare but serious condition that can develop after a viral illness when aspirin is given to children. The toddler’s symptoms—lethargy, persistent vomiting, and difficulty rousing—align with signs of increased intracranial pressure associated with Reye’s syndrome.

• Aspirin administration during a recent influenza A infection is a known trigger for Reye’s syndrome, as it can cause acute encephalopathy and liver dysfunction in pediatric patients.

Rationale for incorrect choices:

• Bronchitis would present with prominent lower respiratory symptoms such as productive cough, wheezing, and abnormal lung sounds, which are not noted here.

• Gastroenteritis is characterized by vomiting and diarrhea with signs of dehydration; this child has no diarrhea, and the neurological decline suggests CNS involvement rather than a purely GI process.

• Acetaminophen administration is not linked to Reye’s syndrome; toxicity causes liver injury but does not present with acute encephalopathy following viral illness in the same way.

• Cough finding is unrelated to the primary cause of the neurological changes and persistent vomiting; the cough has been present but is not the trigger for the current complication.

Correct Answer is C

Explanation

A. "Wear a pair of disposable briefs at bedtime.": Using briefs may provide protection against leakage but does not address the underlying bladder control issue. Bladder retraining focuses on strengthening muscles and establishing voiding schedules.

B. "Limit oral fluid intake to 1,000 milliliters per day.": Restricting fluids can lead to dehydration and urinary tract infections. Adequate hydration is important for bladder health, and fluid restriction is not a recommended strategy for retraining.

C. "Practice pelvic-floor exercises regularly.": Pelvic-floor (Kegel) exercises strengthen the muscles that support bladder control, improve continence, and are a key component of bladder retraining programs. Consistent practice enhances effectiveness over time.

D. "Drink 8 ounces of citrus juice per day.": Citrus juice is not necessary for bladder retraining and may irritate the bladder in some individuals. Dietary recommendations should focus on overall hydration and bladder-friendly fluids rather than specific juices.

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