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","D","E","F"]

Explanation

A. Instruct the client on the use of an incentive spirometer. Although this intervention can improve lung expansion, it is not a priority in this situation, given the possibility of an airborne infectious disease and the need to address systemic and diagnostic concerns first.

B. Request a glucocorticoid prescription from the provider. While glucocorticoids may reduce inflammation, there is no immediate indication they are necessary based on the client's presentation. The priority is diagnosing and managing the underlying infection.

C. Obtain blood cultures. Blood cultures are critical to identify any systemic infection that may be contributing to the client's fever, tachycardia, and worsening symptoms. This helps guide the initiation of appropriate antimicrobial therapy.

D. Obtain a sputum culture. The client’s productive cough with blood, fever, and weight loss raise suspicion for serious respiratory infections, such as tuberculosis (TB) or other pathogens. A sputum culture is necessary to identify the causative organism for targeted treatment.

E. Recommend ABGs be drawn. The client’s oxygen saturation has dropped to 92% on room air, and there is an increase in respiratory rate, indicating possible hypoxemia or impaired gas exchange. Arterial blood gases (ABGs) provide critical information about oxygenation, ventilation, and acid-base status, guiding further interventions.

F. Place the client in a negative-pressure room. The symptoms, including a cough producing blood-tinged sputum, fever, and weight loss, are consistent with a potential diagnosis of TB or another airborne infectious disease. A negative-pressure room prevents the spread of airborne pathogens to others.

G. Administer small, frequent meals. Although the client reports a lack of appetite and weight loss, this intervention is not urgent. Addressing the client’s infection and respiratory status takes precedence.

A. Connect new information with the client's past experiences. B. Use a 12-point font when printing written materials for the client. C. Speak loudly when addressing the client. D. Present the information to the client using abstract concepts.

Correct Answer is A

Explanation

A. Connecting new information with past experiences enhances understanding and retention in older adults.

B. Larger fonts, such as 14-point, are preferable for older adults with vision changes.

C. Speaking clearly, not loudly, is more effective.

D. Concrete, not abstract, information is easier to understand.

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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

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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.