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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:

"Describe your daily medication schedule” is not the correct statement. Understanding the medication schedule is important for adherence to antiretroviral therapy.

Choice B Reason:

"Tell me why it's important to have your CD4+ count checked." Is the correct statement, the priority information for the nurse to review with the client is why it's important to have their CD4+ count checked regularly? The CD4+ count is a crucial marker of immune system health and function in individuals with HIV. Monitoring CD4+ counts help guides treatment decisions, assess the effectiveness of antiretroviral therapy, and evaluate the progression of the disease. Understanding the significance of CD4+ counts is essential for the client's overall management of HIV.

Choice C Reason:

"List some ways you can cope with the stress of your illness" is not the correct statement - Coping strategies are important for the client's emotional well-being and overall health.

Choice D Reason:

"Name a few things you will change about your diet" is not the correct statement. Nutrition is important for overall health, including maintaining a strong immune system, but it may not be the most immediate priority compared to understanding the importance of CD4+ counts.

A. Magnesium B. Potassium C. Phosphatase D. Calcium

Correct Answer is B

Explanation

Choice A Reason:

Magnesium - While magnesium levels can affect cardiac function, hypomagnesemia is not a primary risk factor for digoxin toxicity.

Choice B Reason:

Potassium. An imbalance of potassium can increase the risk of digoxin toxicity. Hypokalaemia (low potassium levels) enhances the binding of digoxin to its target receptors in the heart, leading to an increased risk of digoxin toxicity. It's essential to monitor potassium levels in clients taking digoxin, as maintaining a stable potassium level helps prevent adverse effects associated with digoxin therapy.

Choice C Reason:

Phosphatase - Phosphate levels are not commonly associated with an increased risk of digoxin toxicity.

Choice D Reason:

Calcium - Calcium levels can affect cardiac function, but they are not a primary factor in the development of digoxin toxicity.

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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

A nurse is providing discharge teaching for a client who has HIV. Which of the following information is the priority for the nurse to review with the client?

Correct Answer is B

Explanation

A nurse is caring for a client who is taking digoxin 0.125 mg PO daily and is at risk for developing digoxin toxicity. The nurse should monitor the client for an imbalance of which of the following electrolytes because it can increase the risk for digoxin toxicity?

Correct Answer is B

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.