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 ["A","C","D"]

Explanation

A. Prepare to obtain a wound culture: A culture is necessary if infection is suspected.
B. Restrict fluid intake: Contraindicated as hydration is important to support healing and kidney function.
C. Administer an analgesic: Pain management is crucial postoperatively.
D. Prepare to administer an antibiotic: Antibiotics are indicated for infection prophylaxis or treatment.
E. Initiate supplemental oxygen: Not needed unless signs of respiratory distress or hypoxia are present.

A. Prefers not to look at the stoma site B. Participates in performing ostomy care C. Denies feelings of sadness about the ostomy D. Accepts that sexual activity will decrease

Correct Answer is B

Explanation

A. "Prefers not to look at the stoma site.": Avoidance suggests denial or difficulty accepting the body change.
B. "Participates in performing ostomy care." Active participation in care indicates the client is adjusting to their new body image and accepting their altered appearance.
C. "Denies feelings of sadness about the ostomy.": Denial of emotions does not necessarily mean acceptance. Acknowledging and expressing feelings is important for adjustment.
D. "Accepts that sexual activity will decrease.": This statement reflects resignation rather than acceptance. Many clients with a colostomy maintain an active sexual life.

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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.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of the client who is postoperative following a fasciotomy. Exhibits Which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

A nurse is collecting data from a client who has a newly placed colostomy. Which of the following findings should indicate to the nurse the client has accepted their new altered body image?

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.