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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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Report of menstrual cycle (absent for 3 months): The nurse’s notes state that the client has not had a menstrual period for three months. In hyperthyroidism, menstrual irregularities such as amenorrhea are common due to hormonal imbalance. This supports hyperthyroidism based on the client's current symptoms..
Weight change (unplanned weight loss): The client reports experiencing unplanned weight loss over three months despite having a good appetite. This suggests an increased metabolic rate, which is consistent with hyperthyroidism. Unintentional weight loss despite normal eating is a key indicator.
Skin condition (warm and moist): The client's skin is described as warm and moist during physical assessment. Hyperthyroidism causes increased blood flow and sweat gland activity, leading to this type of skin condition. It reflects the body's accelerated metabolic processes.
Neck exam (goiter visualized): The nurse notes the presence of a visible goiter on neck examination. A goiter indicates thyroid gland enlargement, which occurs in hyperthyroidism due to overstimulation and overproduction of thyroid hormones. This is a major physical finding.
Laboratory results (T3, T4, TSI ordered): The provider orders tests for T3, Free T4, and TSI to evaluate thyroid function. These specific labs are ordered when hyperthyroidism is suspected, particularly TSI which is associated with Graves’ disease. The decision to order them aligns with the findings.
Eye appearance (exophthalmos noted): Exophthalmos, or outward bulging of the eyes, is noted by the nurse. This finding is strongly associated with hyperthyroidism, especially Graves' disease. It occurs due to inflammation and fluid buildup behind the eyes, worsening as thyroid dysfunction progresses.

A. Clamp the urinary catheter tubing. B. Replace the indwelling urinary catheter with a smaller diameter catheter C. Irrigate the bladder with 20 to 30 mL of 0.9% sodium chloride irrigation D. Allow the tubing to hang below the drainage bag

Correct Answer is C

Explanation

A. Clamp the urinary catheter tubing: Clamping the catheter tubing is not appropriate because it can lead to bladder distention, increased pressure, and risk of bladder rupture. Maintaining continuous drainage is essential to prevent complications following prostate surgery.

B. Replace the indwelling urinary catheter with a smaller diameter catheter: Replacing the catheter is not the first intervention when clots and dark red blood are present. Smaller diameter catheters would actually be less effective in clearing clots and could worsen the blockage.

C. Irrigate the bladder with 20 to 30 mL of 0.9% sodium chloride irrigation: Manual irrigation helps to clear clots that may be obstructing the catheter, promoting continued drainage and reducing the risk of bladder distention. Gentle irrigation is the appropriate first step to manage clot formation.

D. Allow the tubing to hang below the drainage bag: The drainage tubing should always be positioned above the collection bag to maintain gravitational drainage. Letting the tubing hang below the bag would impair drainage and could lead to backflow and infection.

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A nurse at a provider's office is caring for a client. Select the 3 findings that require immediate follow-up.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client in a provider's clinic. For each finding of the client, click to specify if the finding is consistent with Hyperthyroidism or Hypothyroidism. Each finding may support more than one disease process.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate. The nurse notes clots and dark red blood in the catheter collection bag. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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A nurse at a provider's office is caring for a client.

Select the 3 findings that require immediate follow-up.