The nurse is assisting with the care of a client.

Exhibits

The nurse is collecting data on the client. Which of the following findings require follow-up?

Abdominal findings

BUN level

Blood píessuíe

Bíeath sounds

WBC count

Potassium level

Answer and Explanation

Correct Answer : A,B,C,F

Choice A rationale: The abdominal findings require follow-up. The client reports mild abdominal pain, rating it as 7 on a scale of 0 to 10, and states they haven’t had a bowel movement in 4 days. Additionally, the physical exam reveals tenderness to palpation and high-pitched bowel sounds in the gastrointestinal area. The CT scan indicates an obstruction in the small intestine, as evidenced by distention with fluid and gas in the small intestine and the absence of gas in the colon. These symptoms suggest a significant gastrointestinal issue that needs further evaluation and management.

Choice B rationale: The BUN level also requires follow-up. The BUN level is elevated at 25 mg/dL, which is above the normal range of 10 to 20 mg/dL. This could indicate dehydration or kidney dysfunction, especially in the context of the client’s symptoms and dry mucous membranes. Elevated BUN levels can be caused by a high-protein diet, dehydration, certain medications, and a variety of medical conditions, including kidney disease.

Choice C rationale: The blood pressure requires follow-up. The client’s blood pressure is low at 92/60 mm Hg. This, combined with an elevated pulse of 106/min, could indicate hypovolemia or dehydration, especially given the client’s vomiting and lack of bowel movements. Hypovolemia refers to a decrease in the volume of blood in the body, which can be caused by a variety of conditions, including dehydration, severe burns, and excessive sweating. Hypovolemia can lead to hypotension (low blood pressure).

Choice D rationale: The breath sounds do not require follow-up. The respiratory examination reveals bilateral breath sounds clear, which is within the normal range. Clear breath sounds indicate that air is flowing smoothly through the bronchial tubes and lungs without obstruction, which is a positive sign.

Choice E rationale: The WBC count does not require follow-up. The WBC count is 9,000/mm, which is within the normal range of 5,000 to

Choice F rationale. Potassium level: The potassium level is low at 3.3 mEq/L (normal range: 3.5 to 5 mEq/L), which can be concerning and may need correction to prevent complications such as cardiac arrhythmias.

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Correct Answer is ["B","C","F"]

Explanation

Choice A rationale:

Initiate a second peripheral IV is generally done to ensure reliable access for medication or fluid administration, especially in situations where multiple interventions are required. However, based on the information provided, there is no immediate indication that a second IV is necessary. The client's symptoms are more focused on managing and monitoring the current situation rather than starting additional IV lines at this point.

Choice B rationale:

Apply oxygen is a recommended action despite the client’s oxygen saturation being 97% on room air. The presence of chest pain and anxiety could indicate that the client may benefit from supplemental oxygen to alleviate symptoms and ensure adequate oxygenation. Applying oxygen can help reduce the client's respiratory distress and improve comfort, especially when experiencing sharp chest pain and rapid, shallow breathing.

Choice C rationale:

Obtain vital signs every 5 minutes is crucial in monitoring the client’s condition closely. Given the client's symptoms of anxiety, chest pain, and abnormal respirations, frequent monitoring will help detect any changes or deterioration in the client’s status. Regular vital sign checks are essential to ensure timely intervention if the client’s condition worsens or if any new symptoms arise.

Choice D rationale:

Perform gastric lavage is not indicated based on the client's symptoms and the information provided. Gastric lavage is typically used in cases of poisoning or overdose, not for symptoms of chest pain and anxiety. Therefore, this action is not appropriate for the client's current presentation.

Choice E rationale:

Prepare to administer anticoagulants is a specific intervention often considered for conditions like suspected pulmonary embolism or myocardial infarction. However, without more information on the client’s cardiac status or specific diagnostic results indicating the need for anticoagulants, this action cannot be recommended solely based on the provided data.

Choice F rationale:

Place the client in high-Fowler’s position is beneficial for improving breathing and reducing the workload on the heart. This position helps in alleviating symptoms related to respiratory distress and can be particularly helpful for clients with chest pain and rapid, shallow respirations. It facilitates better lung expansion and improves oxygenation.

A. Avoid administration of the influenza vaccine. B. Provide a diet that is low in protein. C. Decrease fluid intake to 1,500 mL daily. D. Maintain the patient on bed rest.

Correct Answer is D

Explanation

Choice A rationale

Avoiding administration of the influenza vaccine is not a recommended intervention for a patient experiencing sickle cell crises. Vaccinations are important for patients with sickle cell disease to prevent infections that can trigger crises.

Choice B rationale

Providing a diet that is low in protein is not a recommended intervention for a patient experiencing sickle cell crises. Patients with sickle cell disease need a balanced diet that includes adequate protein to support tissue repair and growth.

Choice C rationale

Decreasing fluid intake to 1,500 mL daily is not a recommended intervention for a patient experiencing sickle cell crises. Adequate hydration is important to prevent sickling of cells and to maintain blood volume.

Choice D rationale

Maintaining the patient on bed rest is the correct intervention. Rest can help to decrease the body’s demand for oxygen, reduce stress on the body, and prevent complications such as acute chest syndrome.

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The nurse is assisting with the care of a client. Exhibits The nurse is collecting data on the client. Which of the following findings require follow-up?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C","F"]

Explanation

A nurse is assisting with the plan of care for a patient who is experiencing sickle cell crises. What interventions should the nurse include in the plan of care?

Correct Answer is D

Explanation

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The nurse is assisting with the care of a client.

Exhibits

The nurse is collecting data on the client. Which of the following findings require follow-up?