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. Widened pulse pressure (not narrowed) is associated with increased ICP.

B. Bradycardia (not tachycardia) is commonly seen in increased ICP due to Cushing’s triad.

C. An increasingly severe headache is a key sign of rising ICP due to increased pressure on pain-sensitive structures.

D. Hypertension, not hypotension, is a characteristic of increased ICP.

A. Battery B. Negligence C. Assault D. Libel

Correct Answer is C

Explanation

A. Battery involves actual physical contact without consent.

B. Negligence refers to failing to provide appropriate care, leading to harm.

C. Assault occurs when a person is threatened with harm or offensive contact, creating fear, even if no physical contact occurs. Telling the client that a catheter will be inserted without consent can be perceived as a threat.

D. Libel is a false written statement that damages someone’s reputation.

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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.