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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 D

Explanation

A. Have the client drink contrast medium: This is incorrect as contrast medium is typically not required for an esophagogastroduodenoscopy (EGD); it is used for other types of imaging studies.
B. Shave the client from axillae to groin: This is incorrect; shaving is not necessary for an EGD procedure.
C. Administer a cleansing enema: This is incorrect as an enema is generally not required for an EGD, which focuses on the upper gastrointestinal tract.
D. Ensure the signed consent is in the medical record: This is correct as ensuring that the consent form is signed and documented is crucial for legal and procedural reasons before performing an EGD.

A. Monthly vitamin B12 injections B. History of kidney stones C. Long-term use of prednisone D. Congenital heart murmur

Correct Answer is C

Explanation

A. Monthly vitamin B12 injections: This is incorrect as vitamin B12 injections are not associated with osteoporosis. They are often used to address vitamin B12 deficiency, which is not a direct risk factor for osteoporosis.
B. History of kidney stones: This is incorrect because while kidney stones can be associated with calcium metabolism issues, they are not a primary risk factor for osteoporosis.
C. Long-term use of prednisone: This is correct as long-term use of corticosteroids like prednisone can lead to decreased bone density and increased risk of osteoporosis due to their impact on bone metabolism.
D. Congenital heart murmur: This is incorrect as a congenital heart murmur is not related to the development of osteoporosis.

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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.

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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.