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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. Changes in the fluid level of the water-seal chamber correspond to the client's breathing pattern. During inhalation, the negative pressure in the chest cavity may cause the fluid level to rise slightly as air is drawn into the tube, and during exhalation, the fluid level may fall as air exits through the chest tube.

A Fluctuations in the fluid level can occur due to changes in suction pressure settings, but this is more relevant to the suction control chamber rather than the water-seal chamber.

C. If there is continuous bubbling in the water-seal chamber, it indicates an air leak, which disrupts the normal function of the water-seal mechanism.

D. The water-seal chamber's fluctuation does not directly indicate lung re-expansion. Lung re-expansion is assessed through clinical examination, chest X-ray, or other diagnostic tests rather than the water-seal chamber.

A. Furosemide B. Desmopressin C. Epinephrine D. Nitroprusside

Correct Answer is B

Explanation

B. Desmopressin is a synthetic analog of vasopressin (antidiuretic hormone) that promotes water reabsorption in the kidneys, reducing urine production. It is used to treat conditions associated with excessive urination, such as diabetes insipidus or nocturnal enuresis. Since the client is experiencing excessive thirst and polyuria (excessive urine output), desmopressin would be appropriate to help reduce urine volume and manage fluid balance.

A Given the client's already high urine output, administering furosemide would further increase urine production, potentially exacerbating fluid loss and dehydration.

C. Epinephrine does not address the underlying issue of excessive thirst and polyuria related to brain injury and would not be used in this context.

D. Nitroprusside is a vasodilator that reduces blood pressure by relaxing smooth muscle in blood vessels. It is used to treat hypertensive emergencies. Nitroprusside is not relevant for addressing excessive thirst and polyuria due to brain injury.

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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

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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Exhibits

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