Click to highlight the findings that require immediate follow-up. (Select all that apply)
Respiratory rate 11/min
SpO2 > 94% on room air
Lungs clear to auscultation
Reports pain worsening in right forearm.
States right hand is “tingly.”
Able to move fingers
The Correct Answer is ["D","E"]
Choice A reason: A respiratory rate of 11/min is slightly below normal (12-20/min) but not immediately concerning in a stable elderly client without respiratory distress. It warrants monitoring but does not require urgent follow-up compared to neurological or musculoskeletal symptoms.
Choice B reason: SpO2 > 94% on room air is normal, indicating adequate oxygenation. This finding does not suggest respiratory compromise, so it does not require immediate follow-up, aligning with expected respiratory status in a stable client.
Choice C reason: Clear lung auscultation is a normal finding, indicating no airway obstruction or fluid. It does not suggest respiratory pathology, so it does not require immediate follow-up, reflecting stable pulmonary function in the client’s assessment.
Choice D reason: Worsening forearm pain after a fall suggests potential fracture, compartment syndrome, or nerve injury, especially in an elderly client. This escalating symptom requires immediate imaging and evaluation to prevent complications like tissue damage, making it critical for follow-up.
Choice E reason: Tingling in the right hand indicates possible nerve compression or injury, such as radial nerve damage from a fall. This neurological symptom demands urgent assessment to prevent permanent impairment, making it a priority for immediate follow-up.
Choice F reason: Ability to move fingers is a positive finding, suggesting some preserved motor function. While reassuring, it does not negate the need to address worsening pain and tingling, so it does not require immediate follow-up compared to other symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Limiting visitors to 2 hours daily is not a standard brachytherapy precaution; time limits depend on radiation exposure, typically 30 minutes per visit. Distance (1 meter) is critical. Incorrect limits risk unnecessary restriction or exposure, compromising safety, essential for managing radiation risks in prostate cancer treatment.
Choice B reason: Dosimeters are worn by staff, not clients, to monitor occupational radiation exposure, not part of client care in brachytherapy. Instructing distance is key. Attaching a dosimeter to the client is irrelevant, risking confusion, and neglecting visitor safety measures, critical for minimizing radiation exposure in treatment settings.
Choice C reason: Instructing visitors to stay 1 meter (3.3 feet) from the client minimizes radiation exposure during low-dose brachytherapy, adhering to ALARA principles. This protects visitors while allowing interaction, critical for safety and psychosocial support, ensuring effective radiation safety management in clients with prostate cancer implants.
Choice D reason: Straining urine is relevant for systemic radiation (e.g., iodine-131), not brachytherapy implants, which are localized. Instructing distance is appropriate. Assuming urine straining is needed risks unnecessary procedures, diverting focus from radiation safety measures, critical for protecting visitors and staff in prostate cancer brachytherapy care.
Correct Answer is D
Explanation
Choice A reason: Peanut butter is sticky and thick, posing a choking risk for dysphagia clients due to difficulty swallowing. Soft, moist foods like scrambled eggs are safer. Recommending peanut butter risks aspiration, potentially causing pneumonia, critical to avoid in stroke patients with impaired swallowing to ensure safe nutrition.
Choice B reason: Soda crackers are dry and crumbly, increasing aspiration risk in dysphagia clients with impaired swallowing from stroke. Scrambled eggs, being soft and moist, are safer. Recommending crackers risks choking or lung injury, delaying safe nutritional intake, essential for recovery and preventing complications in stroke patients.
Choice C reason: Crispy rice bars are hard and crunchy, difficult to swallow for dysphagia clients post-stroke, risking aspiration. Scrambled eggs are soft and safe. Recommending rice bars risks choking or pneumonia, compromising nutritional safety, critical for supporting recovery and preventing respiratory complications in clients with swallowing difficulties.
Choice D reason: Scrambled eggs are soft, moist, and easy to swallow, ideal for dysphagia clients post-stroke, reducing aspiration risk. This choice aligns with speech therapy recommendations, ensuring safe nutrition. Recommending eggs supports recovery, prevents complications like pneumonia, and maintains nutritional status, critical for stroke clients with swallowing impairments.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.