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?

Select all that apply.

Blood pressure

BUN level

Potassium level Abdominal findings

WBC count

Breath sounds

Answer and Explanation

Correct Answer : A,B,C,D

A. Blood pressure: The client’s blood pressure (92/60 mm Hg) is low, which is concerning, especially with tachycardia (HR 106). This may indicate hypovolemia or shock, which requires immediate attention.
B. BUN level: The BUN level (25 mg/dL) is elevated above the normal range, which could indicate dehydration or kidney dysfunction, often seen in conditions like gastrointestinal obstruction or sepsis.
C. Potassium level: The potassium level (3.3 mEq/L) is below the normal range (3.5 to 5 mEq/L), which can contribute to arrhythmias and muscle weakness, often a result of vomiting, diarrhea, or dehydration.
D. Abdominal findings: The high-pitched bowel sounds and tenderness are consistent with an intestinal obstruction, and further assessment and intervention are necessary to manage the condition effectively.
E. WBC count: The WBC count (9,000/mm³) is within the normal range, suggesting no active infection or inflammation at the moment.
F. Breath sounds: Bilateral breath sounds are clear, which suggests no current respiratory issues or pneumonia, allowing the focus to remain on gastrointestinal findings.

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Correct Answer is C

Explanation

A. "Encourage three large meals daily.": Smaller, more frequent meals are often better tolerated, especially if the client has nausea or anorexia.
B. "Season foods with spices.": Spices might irritate the gastrointestinal tract, particularly if mucosal lesions are present.
C. "Provide a high-calorie diet.": Clients with AIDS often have increased energy needs due to hypermetabolism and malnutrition; a high-calorie diet helps maintain weight and energy levels.
D. "Administer an antiemetic after each meal.": Antiemetics should be administered before meals to prevent nausea and improve food intake.

A. The client had a hemorrhoidectomy 1 year ago. B. The client takes ibuprofen for headaches. C. The client consumed citrus juice 3 days before the test. D. The client has a history of breast cancer.

Correct Answer is B

Explanation

A. Hemorrhoidectomy is not likely to cause a false-positive test, as the wound would typically heal and stop bleeding after a year.
B. The client takes ibuprofen for headaches: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can irritate the gastrointestinal (GI) tract, leading to minor bleeding in the stomach or intestines, which can result in a false-positive fecal occult blood test.
C. Citrus juice may alter the pH of the stool but is not a known cause of false-positive results in fecal occult blood tests.
D. Breast cancer is not directly associated with causing false-positive results in fecal occult blood tests.

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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? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has AIDS and has malnutrition. Which of the following actions should the nurse include in the plan of care?

Correct Answer is C

Explanation

A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?

Correct Answer is B

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?

Select all that apply.