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Exhibits

The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up:

Blood glucose level

Bowel sounds

Blood pressure

Pain level

Electrocardiogram findings

Lung sounds

Troponin T level

Answer and Explanation

Correct Answer : C,D,E,G

C. The blood pressure readings show significant variability (164/80 mm Hg at 1000, 176/82 mm Hg at 1015, and 110/62 mm Hg at 1200). These fluctuations, especially the higher readings, indicate potential instability and require close monitoring and possibly intervention.
D. The client's pain level is described as 7/10 initially (1000) and decreases to 5/10 after nitroglycerin (1200). Although the pain has decreased, ongoing assessment is necessary to ensure it does not worsen or change in nature.
E. The 12-lead electrocardiogram (ECG) shows tachycardia with ST segment elevation and T wave changes, which are indicative of myocardial ischemia or infarction. This finding requires immediate attention as it suggests ongoing cardiac damage.
G. The troponin T level is elevated at 0.40 ng/mL (normal is less than 0.1 ng/mL). Troponin elevation indicates myocardial injury or infarction and confirms the seriousness of the cardiac event. This finding requires immediate attention to assess the extent of myocardial damage and guide further treatment.

Incorrect Choices
A. While it is slightly elevated, it is not significantly outside the normal range and does not suggest immediate danger or require urgent intervention in the context of the acute cardiac issue. However, monitoring blood glucose levels is important for overall management, especially in a client with diabetes mellitus.
B. The assessment of bowel sounds being present in all 4 quadrants is a normal finding and indicates normal gastrointestinal function. While bowel sounds are important for assessing gastrointestinal health, they are not immediately pertinent to the acute cardiac issue described in the scenario.
F. The nurse notes that lung sounds are clear to auscultation in all lobes, which is a normal finding. Clear lung sounds suggest normal respiratory function and do not require immediate attention in the context of the acute cardiac event described.

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Correct Answer is B

Explanation

B. This location is preferred because it provides rapid and higher peak plasma epinephrine levels compared to other sites, which is crucial during an anaphylactic emergency.

A While this can be a safe IM injection site in some adults, it's not the preferred location for epinephrine during anaphylaxis. The muscle mass in the ventrogluteal area might be less reliable for quick absorption of the medication in an emergency situation.

C. avoided due to its proximity to major nerves (sciatic nerve) and blood vessels, which can lead to complications such as nerve damage or accidental injection into a blood vessel.

D. The deltoid is generally not recommended because it has a smaller muscle mass compared to the ventrogluteal or vastus lateralis sites.

A. Tie knots in the ropes near the pulleys to shorten them. B. Increase the elevation of the affected extremity. C. Remove one of the weights. D. Pull the client up in bed.

Correct Answer is D

Explanation

D. The appropriate action would be to adjust the patient's position to restore the correct alignment and tension of the traction. This typically involves pulling the client up in bed to ensure that the weights hang freely and exert the necessary force for effective traction.

A It is not recommended to tie knots in the ropes as this action could disrupt the prescribed traction force and alignment.

B. It is helpful for other aspects of care but does not correct the traction issue caused by the weights resting on the floor.

C. This is not the correct action because it would decrease rather than increase the traction force, which is necessary for fracture alignment and healing.

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Exhibits The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer intramuscular epinephrine to a client who is experiencing anaphylaxis. Which of the following sites should the nurse use?

Correct Answer is B

Explanation

A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are resting on the floor. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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Exhibits

The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up: