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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. Initiate oxygen therapy: Sepsis can lead to tissue hypoxia and organ dysfunction due to impaired perfusion. Oxygen therapy is the priority to ensure adequate oxygenation, prevent respiratory failure, and support vital organ function.

B. Administer antibiotics: Broad-spectrum antibiotics are essential to treat the underlying infection, but they should be given after obtaining blood cultures to ensure accurate pathogen identification and prevent delays in appropriate therapy.

C. Obtain blood cultures: Blood cultures must be collected before antibiotic administration to identify the causative organism, but stabilizing the client's oxygenation and perfusion takes precedence in acute management.

D. Begin an IV crystalloid infusion: Fluid resuscitation is crucial for managing septic shock, but oxygen therapy should be initiated first to immediately improve oxygen delivery and prevent hypoxia-related complications.

A. I have a sore that won't get better on my right foot." B. Client removed gauze bandage to reveal open wound 3 cm x 4 cm on right foot C. draining small amount of purulent drainage D. frequent urination E. increased thirst F. recent 4.5 kg (10 lb) weight loss without trying G. Temperature 38.3° C (100.9°F) H. Heart rate 104/min I. Blood pressure 98/74 mm Hg J. Blood glucose 250 mg/dL (74 to 106 mg/dL)

Correct Answer is ["C","D","E","F","G","H","I","J"]

Explanation

Open wound on right foot with purulent drainage: A non-healing wound with purulent drainage suggests infection, which is a major concern in clients with hyperglycemia. Poor wound healing is common in diabetes due to impaired circulation and immune function.
Frequent urination, increased thirst, and unexplained 4.5 kg (10 lb) weight loss: Classic symptoms of hyperglycemia and possible diabetes mellitus. Polyuria and polydipsia result from osmotic diuresis due to high blood glucose levels, while unexplained weight loss may indicate the body breaking down fat and muscle for energy.
Temperature 38.3° C (100.9° F): Fever indicates a possible systemic infection. In diabetic clients, infections can progress rapidly and lead to complications such as cellulitis, osteomyelitis, or sepsis.
Heart rate 104/min: Tachycardia may be a response to fever, dehydration, or underlying infection. Persistent tachycardia could indicate worsening sepsis or hemodynamic instability.
Blood pressure 98/74 mm Hg: While not critically low, this blood pressure is on the lower end and could indicate early signs of dehydration from polyuria or systemic infection.
Blood glucose 250 mg/dL: Significantly elevated blood glucose suggests poor glycemic control, increasing the risk of infection, delayed wound healing, and diabetic ketoacidosis (DKA) if it continues to rise.:

Respiratory rate 18/min: A normal respiratory rate does not indicate respiratory distress or metabolic compensation.
Oxygen saturation 97% on room air: Oxygenation is within the normal range, suggesting no immediate hypoxia.
WBC count 9,500/mm³: Within the normal range, although an infection may still be present given the fever and purulent wound drainage.
Triiodothyronine (T3) 200 mg/dL: Within normal limits, ruling out thyroid dysfunction as a cause of symptoms.
BMI 27: Slightly overweight but not directly contributing to the acute condition.

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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.

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Correct Answer is A

Explanation

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Explanation

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