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 B
Explanation
A. "Our child has a better grasp of reality.": This is not the primary goal of methylphenidate. While it may help with focus and attention, the medication's goal is to improve concentration and reduce hyperactive behaviors in children with ADHD, not directly influence their grasp of reality.
B. "Our child is able to complete his homework on time.": This is correct. Methylphenidate, a stimulant used to treat ADHD, helps improve attention, focus, and impulse control. A child who can complete homework on time demonstrates improved attention and task completion, which is the desired outcome.
C. "Our child has lost some weight since his last appointment.": While weight loss can be a side effect of methylphenidate, it is not an indicator that the medication is effective. The goal is to manage ADHD symptoms, not necessarily to cause weight loss.
D. "Our child has increased his daily caloric intake.": This is incorrect. A common side effect of methylphenidate is decreased appetite, so an increase in caloric intake would not be expected.
Correct Answer is ["B","C","E"]
Explanation
A. "Apply the transdermal patch to either of the client's forearms" is incorrect. The nurse should avoid applying the patch to areas with excessive hair, irritation, or broken skin. Common areas include the upper torso (e.g., upper arm, chest, or back).
B. "Remove the old transdermal patch before applying a new one" is correct. To prevent overdose or accidental administration of an additional dose, the nurse should always remove the old patch before applying a new one.
C. "Apply the patch to a clean, hairless area of the client's skin" is correct. This ensures better adhesion and absorption of the medication, as hair and dirt can interfere with the patch's effectiveness.
D. "Use sterile gloves to apply and remove transdermal patches" is incorrect. Standard gloves are sufficient for applying and removing transdermal patches, as they do not need to be sterile.
E. "Dispose of old transdermal patches in a childproof container" is correct. Fentanyl patches should be disposed of properly to avoid accidental exposure or ingestion by children or pets. A childproof container ensures safe disposal.
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