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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Correct Answer is C

Explanation

A. Encouraging the client to use nearby furniture is unsafe for a client on complete bed rest.

B. Physical therapy is not typically called to assist with bathroom use for an end-of-life client.

C. This response acknowledges the client’s emotional state and opens communication to address their concerns empathetically.

D. Telling the client they "have to" use a bed pan without further discussion may come across as dismissive or insensitive.

A. "I can disconnect the suction to the OG tube while holding my baby." B. "I passed this gene to my baby and there's a chance I could pass it onto my next child." C. "My baby might need to have an ostomy." D. "My baby will need to have a high-calorie formula."

Correct Answer is C

Explanation

A: Disconnecting the suction to the OG tube while holding the baby is not advisable, especially if the baby is on suction due to abdominal concerns such as NEC. The OG tube is used to decompress the stomach, and disconnecting it without proper instructions can worsen the condition. Therefore, this statement indicates a lack of understanding.

B: While genetic factors may influence some neonatal conditions, NEC is not a genetic disorder. The statement about passing a gene to the baby and potentially to the next child is not accurate in this context.

C: Necrotizing enterocolitis (NEC) is a severe gastrointestinal emergency commonly seen in preterm neonates, and it can lead to bowel perforation. In cases of extensive bowel damage or perforation, surgical intervention may be required, including the possibility of an ostomy. This is a correct statement that reflects the understanding of the potential treatment plan for the neonate.

D: NEC typically involves the inability to tolerate feedings, and in such cases, feeding is often withheld temporarily. The baby would not need high-calorie formula in this situation; instead, the focus would be on managing NEC, potentially with IV nutrition or parenteral nutrition (TPN), and addressing the need for surgical intervention.

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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

A nurse is caring for a client who is near the end of life and is on complete bed rest. The client states that he needs to have a bowel movement, and the nurse offers a bed pan. The client states, "I've always used the bathroom." Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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Correct Answer is C

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.