A nurse on a medical-surgical unit is caring for a client.
Which of the following findings indicates a need for follow-up by the nurse? Select all that apply.
Blood pressure
Potassium level
Respiratory rate
Urinary output
Heart rate
Temperature
Oxygen saturation
Skin assesses
Correct Answer : B,D
B. Potassium level: The normal potassium range is 3.5 to 5 mEq/L. The client's potassium level of 5.0 mEq/L is at the upper end of the normal range. While it is within the normal range, it is important to monitor it closely since elevated potassium levels can lead to cardiac dysrhythmias. Therefore, this finding indicates a need for follow-up by the nurse.
D. Urinary output: Urinary output is an important indicator of renal function and fluid balance. If the urinary output is significantly decreased or too low, it could indicate issues with kidney function or inadequate fluid intake. Monitoring urinary output is essential to assess the client's hydration status and kidney function. Therefore, this finding indicates a need for follow-up by the nurse.
Incorrect answers:
A. Blood pressure: Blood pressure is not indicated in the provided laboratory results. It is important to monitor blood pressure, but the information provided does not suggest any abnormality related to blood pressure.
C. Respiratory rate: Respiratory rate is not indicated in the provided laboratory results. It is important to monitor respiratory rate, but the information provided does not suggest any abnormality related to respiratory rate.
E. Heart rate: Heart rate is not indicated in the provided laboratory results. It is important to monitor heart rate, but the information provided does not suggest any abnormality related to heart rate.
F. Temperature: Temperature is not indicated in the provided laboratory results. It is important to monitor temperature, but the information provided does not suggest any abnormality related to temperature.
G. Oxygen saturation: Oxygen saturation is not indicated in the provided laboratory results. It is important to monitor oxygen saturation, but the information provided does not suggest any abnormality related to oxygen saturation.
H. Skin assessment: Skin assessment is not indicated in the provided laboratory results. It is important to assess the skin, but the information provided does not suggest any abnormality related to skin assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Recommending staying at a local shelter might not be appropriate unless the client's health is in immediate danger due to the low temperature. It's better to explore other options first.
Choice B reason:
Contacting the client's family members about their financial status might not be necessary or respectful of the client's privacy without their consent.
Choice C reason:
Contact the local Department of Health and Human Services for the client. Contacting the local Department of Health and Human Services can help ensure that appropriate resources and assistance are provided to the client. They may have programs or services available to assist individuals who are struggling to afford heating during the winter. This action addresses the immediate concern of the client's health and the living environment.
Choice D reason:
Providing information about the dangers of hypothermia is important, but the client's current situation of living in a cold environment should be addressed first. The nurse can provide this information along with appropriate resources to help the client.
Correct Answer is B
Explanation
Choice A Reason:
"I will tell your provider that you do not want to take this medication." - This response does not address the client's concerns and might lead to a confrontational approach.It might also prematurely suggest stopping the medication without discussing potential consequences or alternatives.
Choice B Reason:
"Your provider wouldn't prescribe this medication if it weren't necessary." Response B is the most appropriate and therapeutic response in this situation. It acknowledges the client's concerns while also emphasizing the importance of following the provider's prescription. By reassuring the client that the provider's decision to prescribe the medication is based on their assessment and medical judgment, the nurse promotes trust and encourages the client to comply with the treatment plan.
Choice C Reason:
"Most clients feel better after taking the antibiotic." - While true, this response doesn't directly address the client's specific concern and might not alleviate their doubts.
Choice D Reason:
"If you don't take this medication, you will feel worse." - This response might come across as overly negative and could potentially lead to resistance or defensiveness from the client. It's important to approach the situation with empathy and respect for the client's perspective.
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