Try Naxlex NCLEX-RN (Free-Trial)

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

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

Hematocrit

Oxygen saturation

Activity level

Blood pressure

Temperature

Breath sounds

Pain level

Vitamin B12 level

Answer and Explanation

Correct Answer : A,B,C,D,H

Hematocrit: The client's hematocrit level of 24% is significantly low (normal range: 37% to 47%), indicating anemia. This requires follow-up to determine the underlying cause and initiate appropriate treatment, such as iron supplementation or further investigation.
Oxygen saturation: An oxygen saturation level of 94% is slightly low, especially considering the client's reported shortness of breath. Monitoring is necessary to ensure adequate oxygenation and to assess if supplemental oxygen or further respiratory evaluation is needed.
Activity level: The client reports generalized weakness and increased fatigue, particularly becoming short of breath after minimal exertion (e.g., climbing stairs). This decreased activity level is concerning and may indicate cardiovascular or hematological issues, requiring further assessment and follow-up.
Blood pressure: The blood pressure readings indicate orthostatic hypotension, with a drop from 118/60 mm Hg sitting to 102/50 mm Hg standing. This significant drop suggests potential volume depletion or anemia, which requires follow-up to assess fluid status and ensure safety during ambulation.
Vitamin B12 level: The Vitamin B12 level of 159 pg/mL is slightly below the normal range (160 to 950 pg/mL), indicating potential deficiency. This can lead to anemia and neurological issues. Follow-up is needed to evaluate dietary intake and consider supplementation.

Temperature: The client's temperature of 37° C (98.6° F) is within normal limits and does not indicate a need for follow-up. Monitoring for signs of infection or inflammation is important, but this finding is stable.
Breath sounds: The assessment shows clear and present bilateral breath sounds, which indicate no respiratory distress or abnormalities. This finding does not require follow-up.
Pain level: The client reports no pain or discomfort, which is a positive finding and does not necessitate further follow-up. Ongoing assessment for pain should continue, but current findings are stable.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. 1:1 ratio of P to QRS waves: Atrial fibrillation is characterized by chaotic atrial electrical activity, leading to the absence of distinct P waves. A 1:1 ratio of P to QRS waves is seen in normal sinus rhythm, not atrial fibrillation.

B. Absence of P waves: Atrial fibrillation causes rapid, disorganized atrial depolarization, resulting in the loss of identifiable P waves on ECG. Instead, fibrillatory waves are seen, and the ventricular response is irregularly irregular.

C. Prolonged PR interval: The PR interval represents the time between atrial and ventricular depolarization. In atrial fibrillation, there is no coordinated atrial depolarization, making the PR interval unmeasurable rather than prolonged.

D. Prolonged QT interval: A prolonged QT interval is associated with conditions like electrolyte imbalances, certain medications, and congenital syndromes, but it is not a typical feature of atrial fibrillation.

A. Purulent drainage B. Edema C. Ecchymotic skin D. Erythema

Correct Answer is A

Explanation

A. Purulent drainage: The presence of purulent drainage suggests a possible wound infection, which requires immediate evaluation and potential intervention by the provider. Signs of infection may include increased warmth, redness, swelling, and fever. Culturing the wound and initiating appropriate antibiotic therapy may be necessary.

B. Edema: Mild edema around the surgical site is a common postoperative finding due to localized inflammation and tissue healing. Unless accompanied by other concerning signs like excessive drainage or warmth, it is not typically a cause for alarm.

C. Ecchymotic skin: Bruising around the incision site is expected after surgery due to minor blood vessel trauma during the procedure. It usually resolves without intervention and does not necessarily indicate a complication.

D. Erythema: Some redness around the incision is normal in the early postoperative period as part of the inflammatory response to healing. However, increasing or spreading erythema, particularly with warmth and tenderness, may indicate infection and should be further evaluated.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the results of electrocardiography monitoring for a client who has atrial fibrillation. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is assessing the abdominal wound of a client who is 3 days postoperative following a colon resection. Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

A nurse is reviewing the laboratory results of a group of clients. Which of the following client conditions requires reporting to the local health department?

A nurse is teaching a group of young adult clients about risk factors for hearing loss. Which of the following factors should the nurse include in the teaching? (Select all that apply.)

The nurse has reviewed the provider prescriptions at 1045. Exhibits Which of the following actions should the nurse perform first?

The nurse is reviewing the client's medical record. The nurse is reviewing the client's medical record. Which of the following findings indicates the client's condition has improved? Select all that apply.

A nurse is preparing to administer a blood transfusion to a client. Which of the following actions should the nurse plan to take?

A nurse is providing discharge teaching for a client who had a partial colectomy 2 days ago. Which of the following information should the nurse include in the teaching?

The nurse has reviewed the nurses' notes at 0940, vital signs at 0945, and laboratory reports at 1020. Select the 2 findings that indicate the client's condition is improving.

A nurse is planning care for a client who is 1 day postoperative following an open cholecystectomy. Which of the following interventions should the nurse include in the plan of care?

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

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