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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 D

Explanation

A. Keep insulins stored in the refrigerator: Insulin should be stored in the refrigerator until it is opened. However, once it is open, it can be stored at room temperature for up to 28 days, depending on the manufacturer’s recommendations. It does not require refrigeration for daily use.

B. Inject air into the regular insulin first: When mixing insulins, the nurse should inject air into the NPH insulin (cloudy) first, not the regular insulin (clear). This prevents contamination of the regular insulin vial with the NPH insulin.

C. Aspirate NPH insulin first: After injecting the correct amount of air into the vial, the nurse should draw up the clear insulin (regular) first, followed by the cloudy insulin (NPH) to prevent contamination.

D. Roll the cloudy insulin between the hands several times: NPH insulin is cloudy and needs to be gently rolled between the hands to mix the insulin properly. Shaking the vial can cause air bubbles or break down the insulin.

A. Soiled cat litter B. Pasteurized milk C. Scrambled eggs D. Electric razor

Correct Answer is A

Explanation

A. Soiled cat litter: Clients with HIV are at increased risk for infections, including toxoplasmosis, which can be contracted from handling soiled cat litter. The nurse should instruct the client to avoid contact with cat litter to prevent exposure to these pathogens.

B. Pasteurized milk: Pasteurized milk is safe to consume and does not pose a significant risk for infection in clients with HIV. The pasteurization process kills harmful bacteria, making it safe for immunocompromised individuals.

C. Scrambled eggs: Scrambled eggs are safe to eat as long as they are properly cooked. The risk of infection from eggs is primarily related to undercooking, which is not specific to HIV-positive clients.

D. Electric razor: An electric razor is safe to use, provided it is kept clean and sanitized. Disposable razors or proper hygiene practices can prevent the risk of cuts and infections, which is not specific to HIV-positive individuals.

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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

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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.