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 A
Explanation
A. Advance directives: Advance directives may contain information about the client's wishes for organ donation, along with other end-of-life preferences.
B. Informed consent: Informed consent is related to specific treatments or procedures and does not address organ donation.
C. Provider's prescription: Providers do not write prescriptions for organ donation; it is a legal decision made by the client.
D. Do-not-resuscitate (DNR) order: A DNR order only indicates that no resuscitation should be attempted in the event of cardiac or respiratory arrest.
Correct Answer is A
Explanation
A. Establish eye contact with the other person: Maintaining eye contact demonstrates attentiveness and respect during communication, fostering trust.
B. Passively listen to the other party: Passive listening is ineffective and may lead to misunderstandings. Active listening is preferred for conflict resolution.
C. Use "you" rather than "I" statements to express thoughts: "You" statements can be perceived as accusatory and escalate conflicts. "I" statements help express concerns without blame.
D. Focus on the person, not the problem: Effective conflict resolution focuses on addressing the problem, not assigning blame or targeting individuals.
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