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 A
Explanation
Rationale:
A. Clamp the catheter distal to the injection port: Clamping the catheter allows urine to accumulate in the tubing, ensuring a fresh specimen can be obtained from the sampling port rather than from stagnant urine in the drainage bag, which could be contaminated.
B. Drain the specimen from the drainage bag: Urine in the drainage bag may be old and contaminated, which can lead to inaccurate culture results. Specimens should be collected aseptically from the catheter sampling port.
C. Collect 2 mL of urine for each specimen: For accurate urinalysis and culture, a larger volume typically 3–10 mL for culture and 10–15 mL for routine urinalysis is recommended to ensure enough specimen for testing and repeat analysis if needed.
D. Obtain the urinalysis specimen before the culture specimen: Culture specimens should be collected first to prevent contamination. Performing urinalysis first can alter the bacterial composition of the sample and compromise culture accuracy.
Correct Answer is A
Explanation
Rationale:
A. Increased creatinine: Chronic kidney disease reduces the kidneys’ ability to filter waste products effectively, causing creatinine to accumulate in the blood. Elevated creatinine is a key indicator of declining renal function and is expected in this condition.
B. Increased calcium: Clients with chronic kidney disease often have decreased calcium levels due to impaired vitamin D activation and phosphate retention. Increased calcium would be unusual unless the client is receiving supplementation.
C. Increased bicarbonate: Metabolic acidosis is common in chronic kidney disease because the kidneys cannot adequately excrete hydrogen ions or reabsorb bicarbonate. This typically results in decreased, not increased, bicarbonate levels in the blood.
D. Increased hemoglobin: Anemia frequently occurs in chronic kidney disease due to reduced erythropoietin production by the kidneys. This leads to lower hemoglobin levels, so an increase would not be expected unless treated with erythropoiesis-stimulating agents.
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.