Which descriptions of stool warrant additional follow-up by the nurse? (Select all that apply.).
Solid with red streaks.
Formed but soft.
Brown liquid.
Tarry appearance.
Multiple hard pellets.
Correct Answer : A,C,D,E
A. Solid stool with red streaks may indicate lower gastrointestinal bleeding and requires further evaluation.
B. Formed but soft stool is a normal finding and does not require follow-up.
C. Brown liquid stool may suggest diarrhea or malabsorption issues, warranting further assessment.
D. A tarry appearance can indicate upper gastrointestinal bleeding and requires prompt follow-up.
E. Multiple hard pellets may indicate constipation or dehydration and should be addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The UAP is correctly pulling the client’s auricle up and back and preparing to insert the thermometer1.
Choice A is incorrect because it is not necessary to remind the UAP to locate the thermometer before gently inserting it into the ear.
Choice B is incorrect because the UAP is already demonstrating the correct technique for pulling the client’s auricle up and back1.
Choice C is incorrect because it is not necessary to advise the UAP to hold the thermometer securely in place to obtain the measurement.
Correct Answer is B
Explanation
Hyperkalemia is a condition where there is an elevated level of potassium in the blood.
It can occur in patients with renal disease due to the kidneys’ reduced ability to excrete potassium.
Treatment-related side effects, such as certain medications or chemotherapy, can also contribute to hyperkalemia by altering potassium levels in the body1.
Hyperkalemia can lead to life-threatening cardiac conduction disturbances2.
Therefore, it is important for the nurse to determine the apical pulse rate and rhythm.
Choice A is not correct because comparing muscle strength bilaterally is not the most important intervention for a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L).
Choice C is not correct because measuring color and amount of urine is not the most important intervention for a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L).
Choice D is not correct because assessing strength of deep tendon reflexes is not the most important intervention for a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L).
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