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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Family visits should be limited to 30 minutes per day to minimize their exposure.
A It should be worn consistently by the nurse caring for the client with the radiation implant to monitor their radiation exposure. Giving it to the oncoming nurse at the end of the shift is not appropriate because it does not provide real-time monitoring of radiation exposure for the nurse during their shift.
C. Soiled linens should be kept in the room until the radioactive source is removed to prevent the spread of contamination
D. One should never touch it directly; instead, use long-handled forceps and place it in a lead-lined container for safe disposal.
Correct Answer is B
Explanation
B. Hypotension suggests inadequate perfusion, which could prompt an increase in dopamine dosage to improve blood pressure and perfusion.
A A heart rate of 60/min is within the normal range for adults and may not necessarily indicate a need to increase dopamine dosage unless accompanied by signs of inadequate perfusion
C. Oxygen saturation of 95% is within the normal range and indicates adequate oxygenation. It does not directly inform the need to increase dopamine dosage
D. A respiratory rate of 14/min is within the normal range. Respiratory rate alone does not typically guide dopamine dosage adjustments unless respiratory distress or acidosis indicates poor tissue perfusion.
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