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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.

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Correct Answer is A

Explanation

A. Stop the infusion: Acute hemolytic reactions can occur within minutes of starting a transfusion and are life-threatening. Symptoms such as chills, lower back pain, and nausea indicate a potential reaction, requiring immediate discontinuation of the transfusion to prevent further hemolysis and organ damage.

B. Collect a urine sample: A urine sample helps detect hemoglobinuria, a sign of red blood cell destruction, but it is not the priority. The infusion must be stopped first to prevent further complications before obtaining a urine sample for analysis.

C. Check the client's vital signs: Monitoring vital signs is essential, but the priority is stopping the transfusion to halt the reaction. Vital signs should be checked after discontinuing the infusion to assess the severity of the reaction and guide further interventions.

D. Administer oxygen to the client: Oxygen may be needed if respiratory distress occurs, but stopping the transfusion is the first step to prevent continued exposure to the incompatible blood product. Oxygen therapy should be implemented based on the client's condition after discontinuing the infusion.

A. "This device delivers heat via electrodes that are attached to the affected area." B. "Adjust the dial until you feel a pins-and-needles sensation." C. "You can apply the electrodes directly over sensitive areas of skin." D. "This device requires access to a 220-volt outlet."

Correct Answer is B

Explanation

A. "This device delivers heat via electrodes that are attached to the affected area.": A TENS unit does not use heat for pain relief. It works by delivering low-voltage electrical impulses to the skin, stimulating nerve fibers to reduce pain perception.

B. "Adjust the dial until you feel a pins-and-needles sensation.": The intensity of the electrical stimulation should be adjusted to a comfortable level where the client feels a tingling or pins-and-needles sensation. This indicates that the nerves are being stimulated appropriately for pain relief.

C. "You can apply the electrodes directly over sensitive areas of skin.": Electrodes should not be placed on irritated, broken, or sensitive skin, as this can cause discomfort or skin damage. Placement should follow guidelines to ensure effective and safe pain management.

D. "This device requires access to a 220-volt outlet.": TENS units are battery-operated and do not require a high-voltage power source. This makes them portable and convenient for home use.

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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

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

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