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A nurse is assisting in the care of a newly admitted client.

Exhibits

Which of the following findings should the nurse report immédiately to the provider?Select all that apply.

Urine output

Heart rate

Sodium level

Respiratory status

Pain

Serum amylase level

Mental confusion

Blood pressure

Temperature

Cold, clammy skin

Answer and Explanation

Correct Answer : B,D,G,H,J

Rationale for Correct Options:

Heart rate. The heart rate has increased from 90/min on Day 1 to 132/min on Day 2. This significant elevation is concerning for worsening systemic inflammation, hypovolemia, or sepsis and requires immediate intervention.
Respiratory status. The client initially had diminished breath sounds at the lung bases, but by Day 2, breath sounds are diminished throughout. This suggests worsening respiratory function, possibly due to acute respiratory distress syndrome (ARDS) or pleural effusion, both of which can complicate severe pancreatitis. Immediate assessment and intervention are necessary.
Mental confusion. The client was alert and oriented on Day 1 but is now disoriented to person, place, and time on Day 2. This change in mental status can indicate worsening systemic inflammation, sepsis, hypoxia, or metabolic disturbances such as hypocalcemia. Immediate evaluation is needed.
Blood pressure. While the client’s initial blood pressure was stable at 126/78 mm Hg, the current reading is not provided. If the client is experiencing hypotension, it could indicate worsening shock, requiring urgent intervention.
Temperature. The client’s temperature increased from 37.2 °C (99 °F) on Day 1 to 38.9 °C (102 °F) on Day 2. This suggests a developing infection, such as infected pancreatic necrosis or sepsis, which requires immediate reporting and further evaluation.
Cold, clammy skin. Cold, clammy skin is a sign of poor perfusion, which may indicate impending shock due to worsening sepsis or hypovolemia. This is an urgent finding requiring immediate attention.

Rationale for Incorrect Options:

Urine output. The client’s urine output was documented as 60 mL/hr, which is within the normal range. There is no indication of oliguria or anuria that would require immediate reporting.
Sodium level. The sodium level of 142 mEq/L is within the normal range and does not indicate a critical electrolyte imbalance requiring urgent intervention.
Pain. The client’s pain has increased from 8/10 to 10/10 despite receiving morphine via a PCA pump. While pain management is crucial, worsening pain alone is not the most urgent concern compared to systemic complications like respiratory failure or hemodynamic instability.
Serum amylase level. Although the serum amylase level is significantly elevated at 498 units/L, this is expected in acute pancreatitis and does not necessarily indicate an immediate life-threatening emergency. Trends in amylase and lipase levels are important for monitoring, but they do not require urgent reporting unless accompanied by other signs of deterioration.

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Correct Answer is B

Explanation

A. "I can stop giving my child this medication if he is taking a steroid." Montelukast is a leukotriene receptor antagonist used for long-term asthma management and should not be discontinued without consulting a provider. It can be used alongside inhaled corticosteroids for better asthma control.
B. "I will give this medication to my child once daily in the evening." Montelukast is typically administered once daily in the evening because leukotrienes contribute to airway inflammation and bronchoconstriction, which can be more pronounced at night. Evening administration maximizes its effectiveness in preventing asthma symptoms.
C. "It takes 2 months of scheduled use before this medication is effective." Montelukast begins to show effects within a few days to a few weeks of consistent use, not two months. However, it is not a rescue medication and should be taken regularly for long-term asthma control.
D. "I will give this medication to my child every 2 hours if he is wheezing." Montelukast is not a rescue medication and does not provide immediate relief for acute bronchospasms. A short-acting beta-agonist, such as albuterol, should be used for rapid symptom relief during wheezing episodes.

A. Open curtains between clients in semiprivate rooms. B. Wear shoes with rubber soles. C. Conduct change-of-shift report near the clients' rooms. D. Turn on overhead lights briefly when checking IV lines.

Correct Answer is B

Explanation

A. Open curtains between clients in semiprivate rooms. Keeping curtains closed between clients helps reduce noise, light, and distractions, promoting a more restful environment. Open curtains can increase disturbances and compromise privacy.
B. Wear shoes with rubber soles. Rubber-soled shoes help minimize noise from footsteps, reducing disruptions to clients' sleep. Hard-soled shoes can create unnecessary noise, contributing to environmental stressors in an acute care setting.
C. Conduct change-of-shift report near the clients' rooms. Shift reports should be conducted away from client rooms to limit noise exposure. Conversations near sleeping clients can be disruptive, reducing sleep quality and contributing to stress.
D. Turn on overhead lights briefly when checking IV lines. Bright overhead lighting can disturb clients' sleep. Using a flashlight or dim bedside lighting is a better approach to minimize disruptions while ensuring safe IV checks.

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Body system	Findings
Head, Eyes, Ears, Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Weight gain
Hematologic	Increased bruising Increased bleeding tendency Insomnia
Genitourinary	Darkening of the urine Urinary frequency

A nurse is assisting in the care of a newly admitted client. Exhibits Which of the following findings should the nurse report immédiately to the provider?Select all that apply.

Nursing Test Bank

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A nurse is assisting in the care of a newly admitted client.

Exhibits

Which of the following findings should the nurse report immédiately to the provider?Select all that apply.