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

Exhibits

Which of the following findings require follow-up? Select all that apply.

Oxygen saturation

Blood pressure

Pain level

Hematocrit

Temperature

Activity level

Breath sounds

Answer and Explanation

Correct Answer : A,B,D,F

Rationale for Correct Choices:

Oxygen saturation: The client's oxygen saturation is 94% on room air. While not critically low, given their reported shortness of breath and fatigue, this warrants follow-up. It could be indicative of the severity of their anemia impacting oxygen delivery.
Blood pressure: The client shows signs of orthostatic hypotension, with a significant drop from 132/60 mm Hg (supine) to 102/50 mm Hg (standing). This change can cause dizziness, falls, and worsened fatigue, and it may be related to anemia or volume depletion that needs evaluation.
Hematocrit: A hematocrit of 24% is critically low, indicating significant anemia. This aligns with the client’s symptoms of fatigue and dyspnea and requires prompt intervention to determine the underlying cause, such as iron or B12 deficiency.
Activity level: The client reports shortness of breath with minimal exertion and difficulty keeping up with grandchildren. This functional decline reflects impaired oxygen delivery due to anemia and must be addressed as it affects quality of life and safety.

Rationale for Incorrect Choices:

Pain level: The client reports no pain or discomfort at this time. While pain is common in rheumatoid arthritis, the current lack of pain does not require further assessment or intervention.
Temperature: The client's temperature is 37°C (98.6°F), which is normal. There are no signs of infection or inflammation requiring follow-up based solely on this vital sign.
Breath sounds: Bilateral clear breath sounds indicate that the lungs are not congested and there is no evidence of pulmonary pathology at this time. Therefore, this finding does not require follow-up.

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Correct Answer is A

Explanation

A. Place a towel over the area to be percussed: A towel should be placed over the area to be percussed to protect the skin and to reduce discomfort. This is a standard procedure to ensure that the percussion is effective and comfortable for the client.

B. Ask the client to take shallow, rapid breaths: Shallow, rapid breaths should be avoided during chest percussion. The client should take deep, slow breaths to help mobilize secretions and allow for effective lung expansion. Rapid breathing could increase respiratory distress.

C. Percuss over each area for 10 min: Percussion should not be performed for 10 minutes over each area, it is done for 1-2 minutes over each lung field to help loosen mucus and improve drainage. Prolonged percussion could be harmful and unnecessary.

D. Maintain client positioning for 45 min: Typically, positioning is maintained for short periods (usually 10-15 minutes) depending on the area being targeted for percussion. Prolonged positioning may lead to discomfort or other complications.

A. Metabolic alkalosis B. Metabolic acidosis C. Respiratory acidosis D. Respiratory alkalosis

Correct Answer is B

Explanation

A. Metabolic alkalosis: In metabolic alkalosis, the pH is elevated (above 7.45), and the bicarbonate (HCO3) is increased (above 28 mEq/L). In this scenario, the pH is low (7.12), and HCO3 is low (20 mEq/L), which is not consistent with alkalosis.

B. Metabolic acidosis: In metabolic acidosis, the pH is low (below 7.35), and the bicarbonate (HCO3) is low (below 21 mEq/L), which is consistent with the client's ABG values (pH 7.12, HCO3 20 mEq/L). This suggests the client has metabolic acidosis, which is common in chronic kidney failure due to impaired excretion of acid and decreased bicarbonate.

C. Respiratory acidosis: In respiratory acidosis, the pH is low, and the PaCO2 is elevated (above 45 mm Hg). The PaCO2 in this client is within the normal range (40 mm Hg), making respiratory acidosis unlikely.

D. Respiratory alkalosis: In respiratory alkalosis, the pH would be high, and the PaCO2 would be low (below 35 mm Hg). The client's pH is low (7.12), and the PaCO2 is normal, so respiratory alkalosis is not present.

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A nurse in a provider's office is caring for a client. Exhibits Which of the following findings require follow-up? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing chest percussion on a client who has severe COPD. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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

Exhibits

Which of the following findings require follow-up? Select all that apply.