A nurse is assisting in the care of a client.
The nurse is assisting in the care of the client. Which of the following findings should the nurse report to the provider?
Select the 5 findings the nurse should report.
Bowel pattern
Oxygen saturation
Respiratory assessment.
Temperature
Neurological status
X-ray results
Heart rate
Correct Answer : B,C,D,E,F
B.Oxygen saturation (92% on room air): A drop in oxygen saturation from 96% to 92% indicates impaired gas exchange, which may require oxygen therapy or further evaluation for respiratory compromise.
C. Respiratory assessment (crackles, chest tightness, productive cough with blood): Crackles and productive cough with hemoptysis are concerning for possible tuberculosis (TB) or another serious respiratory infection. Immediate notification ensures timely isolation and further diagnostic testing.
D. Temperature (38.8°C/101.8°F): The elevated temperature indicates a possible infection or worsening inflammatory process, especially concerning given the night sweats and recent international travel history.
E. Neurological status (lethargy): The progression from an alert state to lethargy suggests potential worsening of the client’s condition, possibly due to hypoxia, infection, or sepsis. Early identification is critical for preventing deterioration.
F. X-ray results (calcification in upper lobes): Calcifications in the upper lung lobes are characteristic of previous or latent TB infection. This, combined with the client’s current symptoms, requires prompt reporting to initiate appropriate infection control measures.
Findings Not Reported:
A.Bowel pattern (normoactive, last BM this morning): The bowel pattern is normal and not immediately relevant to the acute respiratory concerns.
G. Heart rate (114/min): Though elevated, the heart rate is likely a secondary response to the fever and respiratory compromise. While important to monitor, it does not warrant immediate provider notification independently.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Maintain IV access. This task requires nursing knowledge and skill to ensure patency and medication administration during a code.
B. Assist with airway intubation. This is a complex procedure that requires advanced training and is performed by licensed personnel.
C. Place defibrillator pads on the client. This task should be performed by trained personnel familiar with defibrillator use and cardiac arrest protocols.
D. Perform CPR on the client. CPR is within the scope of an assistive personnel's responsibilities if they are trained in Basic Life Support (BLS).
Correct Answer is B
Explanation
A. AU (both ears): This abbreviation is not recommended because it can be misinterpreted as referring to the eyes (OU) or ears (AU). The Joint Commission discourages using abbreviations that can lead to errors.
B. ADL (activities of daily living): This is a widely accepted and standardized abbreviation in healthcare documentation. It is not prone to misinterpretation.
C. HS (hour of sleep): HS can be misinterpreted as "half-strength." Therefore, it is not recommended for use in documentation according to best practice guidelines.
D. SQ (subcutaneous): SQ can be misread as "SL" (sublingual) or mistaken for "5 every." The recommended abbreviation is "subcut" or "subcutaneous."
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