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 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.

A. Identifies a sour taste B. Shrugs his shoulders C. Frowns symmetrically D. Sticks his tongue out

Correct Answer is B

Explanation

A. Identifying a sour taste tests cranial nerves VII (facial) and IX (glossopharyngeal).

B. Cranial nerve XI (the spinal accessory nerve) controls the muscles involved in shoulder shrugging and head turning.

C. Frowning symmetrically assesses the facial nerve (VII).

D. Sticking out the tongue assesses the hypoglossal nerve (XII).

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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

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Explanation

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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.