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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 C

Explanation

A. "Plan to void every 6 hours.": Voiding every 6 hours may not be appropriate for clients with stress incontinence. A more individualized schedule based on the client's needs and fluid intake is better. Holding urine for too long could worsen symptoms.

B. "Squeeze your legs together when you feel the urge to void.": This is not effective in managing stress incontinence. Instead, strategies like pelvic muscle exercises (Kegel exercises) can help strengthen the muscles that control urination.

C. "Perform Kegel exercises three times daily.": Kegel exercises help strengthen the pelvic floor muscles, which can reduce stress incontinence by improving bladder control. This is an effective and recommended strategy for managing the condition.

D. "Drink 1 liter of fluids a day.": Restricting fluids can concentrate urine, irritating the bladder and worsening incontinence. It’s generally better to maintain adequate hydration, typically around 2 liters of fluids daily, unless otherwise directed by the healthcare provider.

A. Clients who are intubated are kept in the supine position B. Central lines are inserted into the femoral vein for clients who are obese. C. Clients who have an indwelling urinary catheter are assessed daily to determine if it is still needed. D. Nurses perform hand hygiene for 10 seconds before completing tasks.

Correct Answer is C

Explanation

A. Clients who are intubated are kept in the supine position: Keeping intubated clients in supine position increases the risk of ventilator-associated pneumonia. Elevating the head of the bed to 30-45 degrees is recommended to prevent aspiration and reduce the risk of infections.

B. Central lines are inserted into the femoral vein for clients who are obese: Inserting central lines into the femoral vein is generally avoided because it increases the risk of infection and complications, especially in obese clients. The jugular or subclavian veins are preferred.

C. Clients who have an indwelling urinary catheter are assessed daily to determine if it is still needed: Regular assessment of the necessity of an indwelling urinary catheter is an evidence-based practice to reduce catheter-associated urinary tract infections (CAUTI).

D. Nurses perform hand hygiene for 10 seconds before completing tasks: The recommended duration for hand hygiene is at least 20 seconds to effectively remove pathogens. A 10-second duration is insufficient to prevent the transmission of infections.

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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.

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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.