Try Naxlex NCLEX-RN (Free-Trial)

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

D. A weight loss of 1.8 kg (4 lb) in the past 24 hours indicates effective diuresis (urine output) and reduction in fluid volume, which is the therapeutic goal of furosemide in treating pulmonary edema.

A Furosemide is a loop diuretic that typically causes a decrease in blood pressure by promoting the excretion of excess fluid and sodium from the body.

B. Adventitious breath sounds such as crackles (rales) indicate the presence of fluid in the lungs, which is a characteristic finding in pulmonary edema.

C. A respiratory rate of 24 breaths per minute is within normal range for an adult at rest. While this respiratory rate is not abnormal, it also does not directly indicate whether furosemide is effective in treating pulmonary edema.

A. "I have difficulty swallowing food." B. "I would rather be in a wheelchair than use a walker to get around." C. "I have a hard time with brushing my hair." D. "I've been having problems with bladder control."

Correct Answer is C

Explanation

C. This statement highlights difficulty with a specific ADL (grooming) that OT can assess and intervene to improve independence and quality of life.

A Difficulty swallowing, preference for a wheelchair over a walker, and problems with bladder control may also require medical attention, but they are not directly related to the occupational therapy's primary focus on improving the patient's ability to perform daily activities

B. This statement suggests mobility issues and possibly difficulty with walking due to muscle weakness. While mobility aids such as wheelchairs and walkers are typically addressed by physical therapists, OT can also be involved in evaluating the client's preferences, abilities, and functional mobility needs.

D. While OT primarily focuses on ADLs and functional tasks, bladder control problems typically require evaluation and management by a urologist or specialist in urology.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 administering furosemide 80 mg PO twice daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective?

Correct Answer is D

Explanation

A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should indicate to the nurse that the client needs a referral for occupational therapy?

Correct Answer is C

Explanation

A nurse is caring for a group of clients who are 12 hr postoperative. The nurse should identify that the client who had which of the following procedures is at risk for developing fat embolism syndrome?

A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia. Which of the following assessment findings supports this suspicion?

A nurse on a medical-surgical unit is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?

A nurse is providing teaching for the family of a client who has Alzheimer's disease. Which of the following statements should the nurse include?

Exhibits A nurse is reviewing the client's diagnostic results and vital signs. Which of the following actions should the nurse take?

A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?

A charge nurse receives a call from the house supervisor requesting room assignments for four new clients. Based on the admission diagnoses, which of the following clients requires a private room?

A nurse is preparing a teaching plan for a client who has mucositis related to chemotherapy treatment. Which of the following instructions should the nurse include?

Exhibits

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