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. Perform CPR for a client who is not breathing: CPR is within the scope of trained assistive personnel, but a nurse or advanced provider typically manages it in an emergency scenario.
B. Complete distal capillary refill checks for a client who has an open leg wound: Capillary refill checks require clinical assessment skills, which are outside the AP's scope of practice.
C. Determine which clients need priority medical treatment: Triage and prioritization require clinical judgment, which is the nurse's responsibility.
D. Answer questions from area residents who have health concerns: APs can answer non-clinical questions and provide basic information to area residents.
Correct Answer is D
Explanation
A. Tell the client's partner the charge nurse can provide the results: The charge nurse would still be bound by HIPAA regulations and cannot share the client's information without consent.
B. Tell the client's partner the results of the laboratory tests: Sharing health information without the client’s permission violates HIPAA regulations.
C. Tell the client's partner not to worry about the results: This response dismisses the partner's concerns and does not address the privacy issue.
D. Tell the client's partner to ask the client about the results: This is the appropriate action, as the client has the right to choose whom to share their health information with.
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