Which client assessment should a nurse immediately report to the health care provider?

Report of joint pain by a client who recently started taking arthritis medication.

Report of decreased appetite and difficulty sleeping in a recently widowed client.

Weight loss of two pounds in a client admitted in congestive heart failure.

Diminished breath sounds in a client admitted with pneumonia.

Answer and Explanation

The Correct Answer is D

This is because diminished breath sounds indicate poor oxygenation and ventilation, which can lead to respiratory failure and hypoxia. The healthcare provider should be notified immediately to assess the client and provide appropriate interventions.

Choice A is wrong because joint pain is a common side effect of some arthritis medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs). It does not require immediate attention unless it is severe or accompanied by other symptoms, such as swelling, redness, or fever.

Choice B is wrong because decreased appetite and difficulty sleeping are normal responses to grief and loss. They do not indicate a medical emergency, but rather a need for emotional support and counseling.

Choice C is wrong because a weight loss of two pounds in a client admitted with congestive heart failure is a positive sign that indicates fluid removal and improved cardiac function. It does not require immediate reporting, but rather ongoing monitoring and evaluation.

Normal ranges for vital signs are as follows :

Blood pressure: 90/60 mm Hg to 120/80 mm Hg
Breathing: 12 to 18 breaths per minute
Pulse: 60 to 100 beats per minute
Temperature: 97.8°F to 99.1°F (36.5°C to 37.3°C); average 98.6°F (37°C)

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Correct Answer is C

Explanation

Albumin is a protein that is made by the liver and helps maintain fluid balance in the

body. The normal range for albumin is 3.5 to 5.5 g/dL or 35-55 g/liter. A low albumin level can indicate malnutrition, liver disease, kidney disease, inflammation, or other conditions that affect protein synthesis or loss.

A client diagnosed with Imbalanced Nutrition: Less than Body Requirements would be expected to have a low albumin level due to inadequate protein intake or absorption.

Choice A is wrong because hemoglobin = 14.2 g/dL is within the normal range for males, which is 13.2 to 16.6 g/dL.

Hemoglobin is a protein in red blood cells that carries oxygen throughout the body. A low hemoglobin level can indicate anemia, which can be caused by blood loss, iron deficiency, vitamin B12 deficiency, or other conditions that affect red blood cell production or destruction.

Choice B is wrong because potassium = 4.2 mEq/L is within the normal range for adults, which is 3.5 to 5 mEq/L.

Potassium is an electrolyte that helps regulate fluid balance, nerve impulses, and muscle contractions. A low potassium level can indicate dehydration, diarrhea, vomiting, diuretic use, or other conditions that cause potassium loss. A high potassium level can indicate kidney disease, adrenal insufficiency, acidosis, or other conditions that cause potassium retention.

Choice D is wrong because creatinine = 0.8 mg/dL is within the normal range for adults, which is 0.6 to 1.2 mg/dL.

A. Fatigue related to excessive fluid loss. B. Deficient fluid volume related to dehydration. C. Risk for impaired skin integrity related to irritation. D. Imbalanced nutrition: less than body requirements related to vomiting.

Correct Answer is B

Explanation

This is the priority nursing diagnosis for a client who has had vomiting and diarrhea for the past three days because it poses the greatest threat to the client’s health and well-

being. Fluid loss can lead to hypovolemia, hypotension, shock, electrolyte imbalance, and renal failure.

Choice A is wrong because fatigue is a subjective symptom that may or may not be related to fluid loss.

It is not a priority over fluid volume deficit.

Choice C is wrong because impaired skin integrity is a potential problem that may occur due to irritation from vomiting and diarrhea, but it is not a priority over fluid volume deficit.

Choice D is wrong because imbalanced nutrition is a potential problem that may occur due to vomiting, but it is not a priority over fluid volume deficit.

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Which client assessment should a nurse immediately report to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which serum laboratory test result should the nurse expect for a client diagnosed with Imbalanced Nutrition: Less than Body Requirements?

Correct Answer is C

Explanation

Which nursing diagnosis is priority for a client who has had vomiting and diarrhea for the past three days?

Correct Answer is B

Explanation

When a client reports altered sexuality patterns, the nurse should: (Select all that apply).

When evaluating a client for a tendency toward addictive behaviors, the nurse would expect which findings?

A client with severe bronchial pneumonia has been receiving oxygen, respiratory treatments, antibiotics, and intravenous fluids. Which arterial blood gas result would indicate that the treatment has been effective?

A nurse is attempting to use non-pharmacological treatment for pain control. Which treatment could the nurse delegate to the UAP?

The nurse is assessing an elderly client who has become confused since admission to the hospital two days ago. Which assessment should the nurse complete first?

A nurse assessment of a client diagnosed with an acute loss of consciousness reveals a Glasgow Coma Scale (GCS) of 6. Which nursing diagnosis is the priority?

Which finding, if identified in a client who is being treated for fecal incontinence would indicate that the bowel training is attaining the desired outcome?

A nurse is teaching a client with newly diagnosed hemophilia about home care practices. What statements by the client indicate that teaching has been effective? Select all that apply.