A nurse at a provider's office is caring for a client.
Select the 3 findings that require immediate follow-up.
Respiratory findings
Menstrual period
Vaginal spotting
Oxygen saturation
Heart rate
Temperature
Bowel sounds
Abdominal findings
Correct Answer : A,C,H
- Respiratory findings: The client has a history of asthma and now presents with slight inspiratory wheezes. Although respiratory rate and oxygen saturation are normal, wheezing indicates airway narrowing, which could worsen rapidly and needs prompt follow-up to prevent an acute asthma exacerbation.
- Menstrual period: The client's menstrual period is late by two weeks, but in itself, a late period does not require immediate intervention. It is an important clinical detail but does not demand urgent follow-up unless accompanied by unstable vital signs or other concerning symptoms.
- Vaginal spotting: Scant dark red spotting in a client with a late menstrual period raises concern for an ectopic pregnancy, which can be life-threatening if it ruptures. Spotting, combined with abdominal tenderness and delayed menses, demands immediate evaluation to rule out ectopic pregnancy or miscarriage.
- Oxygen saturation: The oxygen saturation of 97% on room air is within the normal range for a healthy adult. There is no evidence of hypoxemia, so this finding does not require immediate follow-up despite the client’s mild wheezing.
- Heart rate: The heart rate of 90/min is normal and within expected limits for adults. Although the client appears anxious, the heart rate itself does not indicate hemodynamic instability and does not require immediate intervention.
- Temperature: A temperature of 37.3° C (99.1° F) is within the normal range and does not suggest active infection or systemic illness. There is no immediate concern based solely on the client’s current temperature reading.
- Bowel sounds: Hyperactive bowel sounds can be associated with various conditions, including gastroenteritis, early bowel obstruction, or anxiety. While they contribute to the overall clinical picture of abdominal discomfort, they do not, on their own, necessitate immediate follow-up .
- Abdominal findings: Right lower quadrant abdominal tenderness, especially in combination with spotting and late menses, is concerning for an ectopic pregnancy. The possibility of rupture or hemorrhage makes abdominal tenderness a critical finding that requires urgent evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A client who is displaying aggression: Using a gait belt on an aggressive client is unsafe because sudden movements or resistance could lead to injury for both the client and the caregiver. Aggressive behavior requires de-escalation strategies before considering physical assistance or mobility interventions like a gait belt.
B. A client who has had chest trauma: Gait belts should be avoided in clients with chest trauma because the pressure applied around the torso can exacerbate injuries such as rib fractures, pulmonary contusions, or other thoracic complications, posing significant health risks during mobilization.
C. A client who has limited arm strength: A gait belt is appropriate for clients with limited arm strength because it provides secure support around the waist without requiring the client to rely heavily on their upper limbs. It allows for safer ambulation and transfer by offering the caregiver a firm point of control.
D. A client who has a thoracic incision: Applying a gait belt over or near a thoracic incision can interfere with wound healing, cause pain, and increase the risk of wound dehiscence. Alternative methods for assisting mobility should be used for clients with fresh surgical sites in the thoracic region.
Correct Answer is D
Explanation
A. "I will take my inhaler treatment before each meal and at bedtime.": Budesonide is a corticosteroid used for long-term control of asthma, not for timing around meals. It is usually taken at set times daily to maintain airway inflammation control, not specifically related to mealtimes or bedtime alone.
B. "I should use my inhaler before exercising.": Using an inhaler before exercise is a strategy typically applied to short-acting bronchodilators like albuterol to prevent exercise-induced bronchospasm. Budesonide is a maintenance medication and is not intended for pre-exercise use.
C. "I should use my inhaler when I have an asthma attack.": Budesonide is not a rescue inhaler and should not be used during an acute asthma attack. Quick-relief inhalers like albuterol are used for immediate symptom management during asthma exacerbations.
D. "I will rinse my mouth and gargle with water after each inhaler treatment.": Rinsing the mouth after using an inhaled corticosteroid like budesonide is important to prevent oral thrush (candidiasis). This action demonstrates correct understanding of medication use and necessary precautions.
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