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A nurse on a medical-surgical unit is caring for a client.

Exhibits

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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A Reason:

Placing the client in a protective environment is not necessary for C. difficile gastroenteritis. Standard precautions, including diligent hand hygiene and appropriate personal protective equipment, are sufficient.

Choice B Reason:

Obtain a stool specimen with gloves is necessary. Obtaining a stool specimen with gloves is an appropriate nursing action when caring for a client with Clostridium difficile (C. difficile) gastroenteritis. C. difficile is a bacterium that can cause diarrhea and other gastrointestinal symptoms. It's important to follow infection control practices to prevent the spread of the bacteria.

Choice C Reason:

Cleaning surfaces with chlorhexidine is not the preferred disinfectant for C. difficile. Sporicidal agents, such as bleach-based solutions, are recommended to effectively kill the spores of C. difficile.

Choice D Reason:

Washing hands with alcohol-based hand rub is not sufficient for C. difficile. C. difficile spores are resistant to alcohol-based hand sanitizers, so using soap and water for handwashing is recommended to ensure proper removal of the spores.

A. Hct 42% B. WBC count 8.000/mm3 C. INR of 1.6 D. Platelets 95.000/mm

Correct Answer is C

Explanation

Choice A reason:

Hct 42% is not appropriate. This haematocrit value is within the normal range (usually around 36-46% for females and 38-50% for males).

Choice B reason:

WBC count 8,000/mm3 is not appropriate. This white blood cell count is within the normal range (typically around 4,500 to 11,000/mm3).

Choice C reason:

INR of 1.6 An INR (International Normalized Ratio) of 1.6 indicates that the client's blood clotting time is prolonged, which means that they might have a decreased ability to form blood clots. This could pose a significant risk during surgery, as proper blood clotting is important to prevent excessive bleeding. The surgeon needs to be aware of this result to determine if any adjustments to the surgical plan or preoperative medications are necessary to ensure the client's safety.

Choice D reason:

Platelets 95,000/mm3 is not appropriate This platelet count is slightly lower than the normal range (typically around 150,000 to 450,000/mm3), but it might not be low enough to be immediately concerning, especially if the client doesn't have a history of bleeding disorders. However, it's still important for the surgical team to be aware of this value.

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A nurse on a medical-surgical unit is caring for a client. Exhibits Which of the following findings indicates a need for follow-up by the nurse? Select all that apply.

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A nurse on a medical-surgical unit is caring for a client.

Exhibits

Which of the following findings indicates a need for follow-up by the nurse? Select all that apply.