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After receiving a hand-off report what assessment information is the most important and immediate concern for the nurse? Select all that apply.

Appointment the next day

Low oxygen saturation

Previous injection drug user and alcohol misuse

Has productive cough severe enough to keep her awake

Marital status

Fever is present.

Elevated temp. pulse, and respiratory rate

Diagnosis pneumonia

Daughter's name

Answer and Explanation

Correct Answer : B,C,D,G,H

Low oxygen saturation: Low oxygen saturation indicates a potential respiratory compromise and should be addressed promptly to ensure adequate oxygenation and prevent further deterioration.

Previous injection drug user and alcohol misuse: Past injection drug use and alcohol misuse can have significant implications for the patient's health, including increased risk of infections, compromised immune function, and potential withdrawal symptoms. It is crucial for the nurse to be aware of these factors in order to provide appropriate care and support. Has productive cough severe enough to keep her awake: A severe productive cough that disrupts the patient's sleep suggests respiratory distress or possible worsening of the underlying condition. The nurse should assess the patient's respiratory status and implement interventions to alleviate the cough and improve rest.

Elevated temperature, pulse, and respiratory rate: An elevation in vital signs, including temperature, pulse, and respiratory rate, can indicate an infectious or inflammatory process. This warrants further assessment and intervention to manage the underlying condition. Diagnosis pneumonia: The diagnosis of pneumonia indicates a respiratory infection that requires close monitoring and appropriate treatment. The nurse should assess the patient's respiratory status, administer prescribed medications, and implement respiratory hygiene measures.

The following options are not immediate concerns or relevant assessment information:

Appointment the next day: While follow-up appointments are important, they do not require immediate attention upon receiving a hand-off report.

Marital status: Marital status is not typically an immediate concern for the nurse's assessment and care planning.

Daughter's name: The patient's family member's name is not an immediate concern or relevant assessment information for the nurse's immediate care.

Fever is present: While a fever is a symptom of an underlying condition, it is not the most critical concern.

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Correct Answer is B

Explanation

An increased serum potassium level, also known as hyperkalemia, can have adverse effects on the electrical conduction of the heart, potentially leading to life-threatening cardiac dysrhythmias. Therefore, it is crucial to assess the patient's pulse rate and rhythm promptly to identify any abnormal cardiac activity.

Assessing the oxygen saturation (oxygen stats), respiratory rate and depth, and deep tendon reflexes are also important assessments, but they are not the priority in this case. Hyperkalemia primarily affects cardiac function, and prompt identification of any potential cardiac rhythm disturbances is essential to prevent further harm.

A. Uncompensated Respiratory Acidosis B. Fully Compensated Metabolic Acidosis C. Uncompensated Metabolic Alkalosis D. Partially Compensated Respiratory Alkalosis

Correct Answer is C

Explanation

The pH value of 7.5 indicates alkalosis, as it is above the normal range of 7.35-7.45. The elevated bicarbonate (HCO3-) level of 34 mmol/L suggests metabolic alkalosis, as it is higher than the normal range of 22-28 mmol/L. The PaCO2 level of 40 mm Hg falls within the normal range of 35-45 mm Hg.

In this case, the primary disturbance is metabolic alkalosis, which is likely caused by the persistent vomiting leading to excessive loss of gastric acid (hydrogen ions) and chloride ions from the stomach. This loss of acid and chloride results in an imbalance of electrolytes and an increase in bicarbonate levels, leading to metabolic alkalosis.

Since there is no significant deviation from the normal range in the PaCO2 level, the respiratory system has not effectively compensated for the metabolic alkalosis. Therefore, it is considered uncompensated.

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After receiving a hand-off report what assessment information is the most important and immediate concern for the nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In reviewing the electrolytes of a patient, the nurse notes the serum potassium level has increased from 4.3 mEq/L to 5.9 mEq/L. Which assessment does the nurse initiate first to prevent further harm?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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