A nurse is assisting in the care of a newly admitted client.
Which of the following findings should the nurse report immediately to the provider?
Select all that apply.
Heart rate
Pain
Cold, clammy skin
Mental confusion
Respiratory status
Blood pressure
Urine output
Temperature
Sodium level
Correct Answer : A,C,D,F,G,H
A. The heart rate increased from 90/min on Day 1 to 110/min on Day 2, indicating tachycardia. This can signify an underlying issue, such as hypovolemia or sepsis, especially given the other concerning findings.
B. While the pain level increased from 3/10 to 6/10, pain itself is subjective and should be monitored closely. It may require adjustment in pain management but is not immediately life-threatening compared to other findings.
D. The client's confusion and slow response can indicate a change in neurological status, possibly related to electrolyte imbalances, dehydration, or infection. This is a significant finding that requires immediate attention.
C. The client's skin changed from warm and dry to pale, cool, and clammy, suggesting possible shock or hypoperfusion. This is a critical sign that needs to be communicated to the provider.
E. The respiratory rate increased from 18/min to 22/min, indicating mild respiratory distress. While concerning, it does not represent an acute emergency compared to other findings and should be monitored.
F. The blood pressure dropped from 126/78 mm Hg on Day 1 to 80/60 mm Hg on Day 2, indicating possible hypotension. This change could signify worsening clinical status, potentially indicating shock or significant fluid loss.
G. The urine output decreased significantly from 400 mL over 8 hours to 100 mL over 6 hours, indicating possible acute kidney injury or dehydration.
H. The client’s temperature has increased from 37.2°C (99°F) to 38.4°C (101.1°F), indicating a possible infection or inflammatory response.
I. The sodium level remains within normal limits (144 mEq/L) and does not show significant changes. Therefore, it does not require immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. Chadwick's sign is a bluish or purplish discoloration of the vaginal and vulvar tissues due to increased vascularity that occurs during pregnancy. This is a normal finding in early pregnancy.
B. Incorrect. Chloasma refers to the appearance of dark patches on the skin, often seen on the face, and is not related to the vaginal and vulvar color changes seen in Chadwick's sign.
C. Incorrect. Hegar's sign refers to the softening of the cervix and isthmus of the uterus, not the color changes in the vaginal and vulvar tissues.
D. Incorrect. Ballottement is a physical examination technique used to assess a floating mass in the body, such as a fetus, and is not related to the color changes in the vaginal and vulvar tissues.
Correct Answer is B
Explanation
A. Incorrect. Plaster casts are not waterproof and can become weakened if exposed to moisture, so showering with the cast is generally not recommended.
B. Correct. Elevating the extremity can help reduce swelling and promote comfort after the cast is applied.
C. Incorrect. Using a hair dryer inside the cast can cause burns and is not recommended for relieving itching.
D. Incorrect. Keeping the cast covered is not necessary, and covering it can trap moisture, potentially causing skin problems.
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