Exhibits

Click to highlight the assessment findings that require immediate follow up by the nurse.

Client is admitted to the medical floor. She has mild subcostal retractions and is sitting in an upright position. Wheezes are noted throughout the lung fields. The client is pale. She has strong peripheral pulses that are equal bilaterally. Her heart rate is 122 beats/minute, blood pressure 134/85 mm Hg, oxygen saturation 91% on room air.

mild subcostal retractions

Wheezes are noted throughout the lung fields

The client is pale

She has strong peripheral pulses that are equal bilaterally

oxygen saturation 91% on room air

heart rate is 122 beats/minute

Answer and Explanation

The Correct Answer is ["A","B","C","E","F"]

Client is admitted to the medical floor. She has mild subcostal retractions and is sitting in an upright position. Wheezes are noted throughout the lung fields. The client is pale. She has strong peripheral pulses that are equal bilaterally. Her heart rate is 122 beats/minute, blood pressure 134/85 mm Hg, oxygen saturation 91% on room air.

Rationale:

An oxygen saturation level of 91% indicates hypoxemia, which is concerning and requires immediate intervention. Normal oxygen saturation levels should be between 95% and 100%. The nurse should assess the client further and consider supplemental oxygen or other interventions to improve oxygenation.

Wheezing suggests bronchoconstriction, indicating that the client is experiencing significant respiratory distress. Given her history of asthma and the ineffectiveness of her usual albuterol dose, further assessment and potential escalation of treatment (such as systemic corticosteroids or nebulized medications) are warranted.

Pallor can be a sign of decreased perfusion or oxygenation and may indicate a worsening respiratory condition. This finding requires further evaluation of vital signs and potential interventions to address the underlying cause.

Tachycardia (elevated heart rate) may indicate stress or inadequate oxygenation, especially in the context of respiratory distress. The nurse should monitor the client's cardiovascular status closely and consider the need for interventions.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Notifying the healthcare provider about allergies to iodine or shellfish is crucial, as IVP contrast agents often contain iodine, and allergic reactions can occur. This is a safety measure that can prevent adverse reactions.

B. While keeping the legs straight may be necessary during the procedure, there is no requirement for them to be kept straight for 6 to 8 hours afterward.

C. While hydration is important, the focus should be on hydration after the procedure to help flush out the contrast material rather than specifically drinking large volumes before the procedure.

D. Inserting an indwelling urinary catheter is not routinely required for IVP unless specified by the healthcare provider; preparation usually focuses on the client’s hydration and allergy history.

A. Abdominal cramps. B. Diarrhea and flatulence. C. Muscle pain. D. Altered taste.

Correct Answer is C

Explanation

A. Abdominal cramps may occur with lovastatin but are generally not serious and do not require immediate intervention. They can often be managed with dietary changes or over-the-counter medications.

B. Diarrhea and flatulence are common side effects that, while uncomfortable, are not typically life-threatening and do not warrant urgent follow-up.

C. Muscle pain, or myopathy, is a significant side effect of lovastatin that can lead to serious complications such as rhabdomyolysis. This condition can cause kidney damage, so any report of muscle pain in a patient taking lovastatin requires immediate follow-up.

D. Altered taste is not a serious side effect and usually does not necessitate urgent intervention, although it may be bothersome to the patient.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When preparing a client for an intravenous pyelogram (IVP), it is essential for the nurse to take which action?

Correct Answer is A

Explanation

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

Correct Answer is C

Explanation

An older adult client who fell at the store is admitted with a possible fracture of the right hip. Which assessment finding should the nurse report to the healthcare provider?

After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?

A client who is receiving radiation treatment for laryngeal cancer has developed xerostomia and mucositis. The nurse determines the client has an imbalanced nutritional intake and is consuming less than body requirements. Which factor is the most likely cause for this problem?

While taking vital signs, a critically ill male client grabs the nurse's hand and asks the nurse not to leave. What action is best for the nurse to take?

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

A client with septic shock develops disseminated intravascular coagulation (DIC). Which pathophysiologic process should the nurse recognize as the cause of the coagulation problem?