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A nurse on a medical-surgical unit is assisting in the care of a male client.
Exhibits
Which of the following findings indicate a need for follow-up by the nurse? Select all that apply.

Temperature

Heart rate

Skin findings

Respiratory rate

Oxygen saturation

Blood pressure

Urinary output

Answer and Explanation

Correct Answer : B,F,G

A. Temperature: The temperature remains stable and within normal limits. A postoperative temperature range of 36.3° C (97.3° F) to 36.4° C (97.5° F) is not indicative of infection or other complications at this time.

B. Heart rate: The heart rate has increased from 84/min to 104/min, indicating sinus tachycardia. This could be a compensatory response to decreased blood volume or another underlying issue, necessitating further assessment.

C. Skin findings: The skin findings are described as warm and dry, which is normal. No abnormalities are noted, so this does not require follow-up.

D. Respiratory rate: The respiratory rate has increased slightly to 24/min but is not significantly abnormal. This may not be a priority for follow-up unless other symptoms are present.

E. Oxygen saturation: The oxygen saturation is within normal limits (96% on room air), suggesting adequate oxygenation. No immediate concerns are evident based on this measurement.

F. Blood pressure: The blood pressure has dropped from 106/74 mm Hg to 88/54 mm Hg, indicating possible hypotension. This drop could signal hypovolemia or bleeding, requiring prompt follow-up to investigate the cause.

G. Urinary output: The urinary output of 110 mL over 6 hours is low, which might indicate dehydration or renal issues. Monitoring and addressing this finding are important to ensure adequate fluid balance and kidney function.

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Correct Answer is B

Explanation

A. Suggest fresh fruits and vegetables: This is incorrect because clients with HIV, especially those with immunosuppression, might be at increased risk for foodborne illnesses from fresh produce. Proper food handling and possibly cooked vegetables might be recommended instead.
B. Offer small, frequent meals: This is correct because small, frequent meals can help manage symptoms like nausea or loss of appetite, which are common in clients with HIV.
C. Provide a diet of pureed foods: This is unnecessary unless the client has specific swallowing difficulties. Generally, pureed foods are not required unless indicated by the client's condition.
D. Encourage fluids with meals: This is incorrect as consuming large amounts of fluids with meals may lead to early satiety, which is not ideal for clients needing to maintain or gain weight.

A. Offer snacks that are high in sodium. B. Place the head of the client's bed flat. C. Monitor the client's weight once per week. D. Provide rest periods throughout the day.

Correct Answer is D

Explanation

A. Offer snacks that are high in sodium: This is incorrect as high sodium intake can exacerbate heart failure by increasing fluid retention and worsening symptoms.
B. Place the head of the client's bed flat: This is incorrect because elevating the head of the bed helps reduce shortness of breath and improves comfort in heart failure patients.
C. Monitor the client's weight once per week: This is incorrect; daily weight monitoring is recommended to detect fluid retention or loss, which can be critical in managing heart failure.
D. Provide rest periods throughout the day: This is correct as providing rest periods helps manage fatigue and reduce the workload on the heart, which is important in heart failure management.

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A nurse on a medical-surgical unit is assisting in the care of a male client. Exhibits Which of the following findings indicate a need for follow-up by the nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is assisting with the plan of care for a client who has heart failure. Which of the following interventions should the nurse recommend?

Correct Answer is D

Explanation

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A nurse on a medical-surgical unit is assisting in the care of a male client.
Exhibits
Which of the following findings indicate a need for follow-up by the nurse? Select all that apply.