A nurse is reviewing the client's electronic medical record.

Exhibits

Which of the following findings require follow up? Select all that apply.

Blood pressure

Temperature

Potassium level

WBC count

Breath sounds

Answer and Explanation

Correct Answer : B,D,E

A. Blood pressure – The client's blood pressure of 114/56 mm Hg is within an acceptable range and does not indicate hypotension or hypertension.

B. Temperature – A temperature of 38.6°C (101.5°F) is indicative of fever, which is concerning in a client undergoing chemotherapy due to their increased risk of infection (febrile neutropenia). Prompt evaluation and intervention are necessary to prevent sepsis.

C. Potassium level – The client's potassium level of 3.6 mEq/L is within the normal range (3.5 to 5 mEq/L) and does not require immediate intervention.

D. WBC count – The client's WBC count has decreased to 3,800/mm³, which is below the normal range (5,000 to 10,000/mm³), indicating leukopenia. This places the client at a higher risk for infection, requiring close monitoring and potential interventions.

E. Breath sounds – The presence of crackles at the lung bases suggests possible pulmonary complications, such as fluid overload, infection (e.g., pneumonia), or early signs of acute respiratory distress syndrome (ARDS). This finding warrants further assessment and intervention.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

“It is important that our child avoids placing anything inside the cast.”: This reflects an understanding. Inserting objects inside the cast can cause injury, skin breakdown, or infection, and should be avoided.

“We should notify the provider if the cast becomes loose over time.”: This reflects an understanding. A loose cast could lead to inadequate immobilization or further injury. Parents should report any loosening to the provider.

“We should prop the casted arm on pillows for the next 24 hours.”: This needs reinforcement. The cast should be elevated to reduce swelling, but it should not be kept elevated for 24 hours continuously. Parents should be taught to elevate the arm in intervals and monitor for signs of increased swelling or discomfort.

“We need to be very careful about how we handle the cast for the first 2 days while it dries.”: This reflects an understanding. It is important to handle the cast with care while it is drying to prevent deformities or indentations in the cast that could interfere with proper healing.

A. Position the client's knees slightly higher than the hips when up in a chair. B. Keep an abduction pillow between the client's legs. C. Raise the head of the client's bed to a high-Fowler's position. D. Elevate the client's affected leg on a pillow when in bed.

Correct Answer is B

Explanation

A. Positioning the knees higher than the hips could increase the risk of hip dislocation.

B. Keeping an abduction pillow between the legs helps maintain the hip in the correct position and prevents dislocation.

C. Raising the head of the bed to a high-Fowler’s position may strain the hip and is not recommended for dislocation prevention.

D. Elevating the affected leg on a pillow may cause internal rotation and increase the risk of dislocation.

View Question and Answer

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A nurse is reviewing the client's electronic medical record. Exhibits Which of the following findings require follow up? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

A nurse is caring for a client who is postoperative following total hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation of the prosthesis?

Correct Answer is B

Explanation

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A nurse is reviewing the client's electronic medical record.

Exhibits

Which of the following findings require follow up? Select all that apply.