Exhibits
A nurse is reviewing the medical record of a client who has COPD. Which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)
Platelet count
Sputum color
Temperature
Fluid intake
The Correct Answer is C
A. Platelet count is normal (175,000/mm3) and does not require reporting to the provider.
B. Sputum color: While thick green sputum might suggest infection, the nurse should first assess for other clinical signs, and it might not need immediate reporting unless there are other concerns, like a change in respiratory status.
C. Temperature (38°C / 100.4°F) is elevated, which could indicate an infection, such as a respiratory infection or exacerbation of COPD. This finding should be reported to the provider because fever in a client with COPD could lead to complications like pneumonia or exacerbation of symptoms.
D. Fluid intake of 2,200 mL/24 hr is within normal limits and does not need reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A. "The client in room 204 received some pain medicine earlier today." is incorrect. This statement is not specific enough to be relevant during change-of-shift report, as the timing of medication administration is important for the next nurse to know and track. A more precise update would be more helpful.
B. "The client in room 205 has had several visitors." is incorrect. While visitation may be useful to mention if it affects the patient's condition or treatment, it's not essential information for the nurse taking over the care of the client.
C. "The client in room 205 is scheduled for a dressing change at 1800." is correct. This provides necessary information about a planned procedure and ensures the next nurse is aware of it for timely management.
D. "The client in room 203 will undergo surgery at 0900 tomorrow." is correct. This provides critical information regarding the client's schedule and helps the next nurse prepare for the upcoming surgery.
E. "The client in room 204 has a new prescription for IV gentamicin." is correct. This is important information for the next nurse, as it indicates a change in the client's treatment plan and ensures appropriate medication administration.
Correct Answer is C
Explanation
A. "I should perform a self-examination of my testicles weekly" is not recommended. Testicular self-exams should be done monthly, not weekly, as this frequency is enough to notice any changes or abnormalities.
B. "I should bear down when cupping my testes while I'm checking for abnormalities" is incorrect. There is no need to bear down during the self-examination. The testicles should be examined gently and without exerting pressure, as bearing down can make the examination uncomfortable.
C. "I should apply gentle pressure with my thumb and forefinger when examining my testes" is the correct statement. The testicular self-exam should be done gently, with light pressure to feel for any lumps or abnormalities.
D. "I should expect one testicle to be larger than the other" is a common misconception. It is normal for one testicle to be slightly larger than the other, but this should be checked regularly to ensure there are no significant changes or signs of concern.
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