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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.)

A.

Platelet count

B.

Sputum color

C.

Temperature

D.

Fluid intake

Answer and Explanation

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.


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Related Questions

Correct Answer is C

Explanation

A. Assign clients to the remaining staff is not the first action. The nurse should address the suspected impairment of the staff member before assigning clients to others.

B. Call the supervisor to ask for another nurse is not the first action. While notifying the supervisor is important, the nurse should first ensure that the impaired nurse is removed from direct client care to prevent any potential harm to clients.

C. Remove the nurse from the client care area is correct. The first priority is to ensure that the nurse who may be impaired is not caring for clients to ensure client safety.

D. Document objective findings about the situation is important but not the first step. The immediate priority is ensuring the safety of clients by removing the nurse from the care area. Documentation can follow after ensuring client safety.

Correct Answer is A,D,C,E,B

Explanation

  1. A. Obtain a baseline reading of the FHR and contraction pattern.
    • Establishing a baseline of fetal heart rate (FHR) and contraction pattern is crucial to assess for any immediate changes following the amniotomy.
  2. D. Position the client with a rolled towel under her hips.
    • Positioning the client with a rolled towel under her hips helps to relieve pressure on the vena cava, improve uterine blood flow, and optimize fetal positioning.
  3. C. Pass the sterile hook to the provider.
    • The sterile hook is used to break the amniotic sac, and the nurse should pass it to the provider during the procedure.
  4. E. Check the fluid for color, odor, and consistency.
    • After the amniotomy, the nurse should assess the amniotic fluid for color (should be clear), odor (should be odorless), and consistency to check for any signs of meconium or infection.
  5. B. Document the procedure in the electronic medical record.
    • The nurse should document the amniotomy procedure and any findings (e.g., FHR changes, amniotic fluid assessment) in the medical record after the procedure has been completed.

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