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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 D

Explanation

Choice A Reason:

Blurred vision is incorrectly. Blurred vision is not a common complication of immobility and is more likely related to other factors.

Choice B Reason:

Polyuria is incorrect. Increased urination (polyuria) is not directly related to immobility; it can be caused by various factors, such as fluid intake, medications, or underlying medical conditions.

Choice C Reason:

Diarrhea is incorrect. While immobility can contribute to constipation due to reduced activity and decreased bowel motility, it is not typically associated with diarrhea

Choice D Reason:

Confusion is correct. Confusion can be a potential complication of immobility in bedridden clients. Prolonged immobility can lead to reduced sensory stimulation, altered sleep patterns, and decreased cognitive engagement, which can contribute to confusion and cognitive decline.

A. Recommend staying at a local shelter until the client can afford the bill. B. Contact the client's family members to tell them the client's financial status C. Contact the local Department of Health and Human Services for the client D. Provide the client with written information about the dangers of hypothermia

Correct Answer is C

Explanation

Choice A reason:

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.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

Correct Answer is C

Explanation

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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.