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 D
Explanation
Choice A reason:
"use my heating pad on a low setting to keep my feet warm". This statement is incorrect. Using a heating pad, especially on a low setting, is not recommended for individuals with PAD. It can lead to burns or skin damage due to reduced sensation in the feet.
Choice B reason:
"rest in my recliner with my feet elevated for about an hour every afternoon" This statement is incorrect. While elevating the feet can help with blood circulation, it's important to avoid prolonged periods of inactivity. Regular physical activity is important for improving circulation.
Choice C reason:
"soak my feet in hot water before trimming my toenails". This statement is incorrect. Soaking feet in hot water can cause burns or damage to the skin for individuals with reduced sensation due to PAD. Trimming toenails should be done carefully and without soaking to prevent injury and infection.
Choice D reason:
"apply a lubricating lotion to the cracked areas on the soles of my feet every morning “This statement is correct. Clients with peripheral arterial disease (PAD) are at risk of reduced blood circulation to the extremities, including the feet. Proper foot care is crucial to prevent complications such as non-healing wounds or infections. Applying a lubricating lotion to cracked areas can help keep the skin moisturized and prevent further complications.
Correct Answer is B
Explanation
Choice A Reason:
A raised lesion with a rolled border - This description might be more indicative of basal cell carcinoma, a different type of skin cancer.
Choice B Reason:
An irregular lesion with irregular borders. Melanoma is a type of skin cancer that originates from melanocytes, the cells responsible for producing the pigment melanin. One of the key characteristics of melanoma is the presence of an irregularly shaped lesion with irregular borders. Melanomas often have uneven, jagged, or notched edges that distinguish them from benign moles or lesions.
Choice C Reason:
A reddened lesion with dilated blood vessels - This description might be more indicative of a vascular lesion or hemangioma, which is not a melanoma.
Choice D Reason:
A scaly lesion with a crusted appearance - This description might be more indicative of squamous cell carcinoma, another type of skin cancer.
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