A nurse is reviewing the client's electronic medical record.
Which of the following findings require follow up? Select all that apply.
Blood pressure
Temperature
Potassium level
WBC count
Breath sounds
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Verbal de-escalation by acknowledging the client’s emotions (“You seem to be very upset”) helps to diffuse tension and can prevent further agitation.
B. Initiating seclusion should be a last resort after other de-escalation techniques fail.
C. Engaging the panic alarm is necessary only if the client becomes physically violent.
D. Using a face shield is not warranted unless there is a risk of bodily fluid exposure.
Correct Answer is []
Explanation
Potential condition: Deep vein thrombosis
Based on the provided information, the client is most likely experiencing Deep Vein Thrombosis (DVT). This is suggested by the client's history of smoking, lack of exercise, obesity, recent surgery, and the fact that they are not wearing sequential compression devices due to discomfort.
Actions to Take
- Request a prescription for a lower-extremity Doppler flow study: This will help confirm the presence of a blood clot in the deep veins.
- Assess for Homan's sign: This is a clinical test used to check for DVT, although it's not always reliable.
Parameters to Monitor
- Signs of bleeding after anticoagulation initiation: This is crucial because anticoagulants are often used to treat DVT, and monitoring for bleeding is essential.
- PT/INR and platelet count: These parameters help assess the effectiveness and safety of anticoagulation therapy.
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