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 D
Explanation
A. Request an interpreter of a different sex from the client: The interpreter’s sex should ideally match the client’s preference for comfort and privacy, but this is not the first action. The priority is understanding facility policy and proper use of interpreters.
B. Request a family member or friend to interpret information for the client: Using family or friends can lead to miscommunication, breaches of confidentiality, or bias. Professional interpreters are preferred to ensure accurate and complete information.
C. Direct attention toward the interpreter when speaking to the client: When using an interpreter, the nurse should maintain eye contact and direct communication to the client, not the interpreter, to foster rapport and respect.
D. Review the facility policy about the use of an interpreter: Reviewing policy ensures that the nurse follows legal, ethical, and professional guidelines for language access services. This is the appropriate first action before arranging or using an interpreter.
Correct Answer is A
Explanation
A. "Since I retired, I have entered many gardening competitions.": Compensation involves emphasizing a strength or engaging in alternative activities to make up for perceived deficiencies or losses. Participating in competitions reflects the client redirecting energy to excel in another area, consistent with this defense mechanism.
B. "I'm so glad I've retired because the work was making me sick and depressed.": This statement reflects relief and rationalization rather than compensation, as the client is explaining the retirement in terms of health and well-being.
C. "There were lay-offs at my company, so I journaled about what I accomplished during my career.": Journaling is a coping strategy that promotes reflection and self-esteem, but it is more aligned with intellectualization or sublimation, not compensation.
D. "I had to retire because my boss didn't like me.": This statement demonstrates projection, attributing responsibility for a situation to someone else, rather than compensating for perceived loss or inadequacy.
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