Try Naxlex NCLEX-RN (Free-Trial)

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

Temperature

Blood pressure

Pain

Urine output

Heart rate

Respiratory status

Sodium level

Mental confusion

Serum amylase level

Cold, clammy skin

Answer and Explanation

Correct Answer : A,B,E,F,H,J

A. Temperature: The client’s temperature increased from 37.2°C (99°F) to 38.9°C (102°F), indicating a possible infection or systemic inflammatory response. Fever in acute pancreatitis can suggest worsening inflammation, infection, or sepsis and should be reported immediately.
B. Blood pressure: The client's blood pressure dropped from 126/78 mmHg to 92/48 mmHg, indicating hypotension, which could be due to fluid shifts, systemic inflammation, or early shock. Immediate intervention is necessary to prevent hemodynamic instability.
C. Pain: While severe pain (rated 10/10) is expected in acute pancreatitis, it is not the most urgent concern requiring immediate reporting compared to hemodynamic instability and respiratory distress.
D. Urine output: The current urine output is not critically low (50-60 mL/hr), but continued monitoring is necessary. However, it is not an immediate life-threatening concern requiring urgent reporting.
E. Heart rate: The client’s heart rate increased from 90/min to 132/min, which is a significant tachycardia. This suggests compensatory shock, fluid loss, or worsening systemic inflammation and requires immediate provider notification.
F. Respiratory status: The respiratory rate increased from 18/min to 32/min, and oxygen saturation dropped to 88% on 3 L/min O₂. This suggests respiratory compromise, possibly due to worsening systemic inflammation, pleural effusion, or acute respiratory distress syndrome (ARDS).
G. Sodium level: The sodium level remains within the normal range (142 mEq/L; normal: 136-145 mEq/L), so it does not require immediate reporting.
H. Mental confusion: The client, who was alert on Day 1, is now disoriented. This change in mental status can indicate worsening systemic inflammation, hypoxia, or impending shock, requiring urgent intervention.
I. Serum amylase level: While elevated (498 units/L), this is expected in pancreatitis and does not require immediate notification unless there is a sudden drastic change.
J. Cold, clammy skin: This is a sign of poor perfusion and possible shock. It indicates worsening hemodynamic instability and requires immediate intervention.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A) Tonic-clonic seizures: Tonic-clonic seizures are typically the result of a seizure disorder, but during electroconvulsive therapy (ECT), a controlled seizure is intentionally induced to facilitate the therapeutic effects. After the procedure, there should not be uncontrolled tonic-clonic seizures. The goal is to induce a seizure under controlled conditions during the procedure itself, so this is not an expected finding 15 minutes post-ECT.

B) Paresthesias: Paresthesias (tingling or numbness) are not a common immediate side effect following ECT. While ECT can have some neurological effects, paresthesias are more commonly associated with other neurological conditions or nerve injuries, rather than as a direct result of the procedure itself.

C) Sleep apnea: Sleep apnea is not a typical immediate consequence of ECT. While ECT can have a range of physical and psychological side effects, sleep apnea, which involves breathing interruptions during sleep, is not an expected finding following the procedure.

D) Disorientation: Disorientation is a common and expected finding following ECT. It typically occurs due to the temporary effects of anesthesia, the brain’s response to the electrical stimulation, and the stress of the procedure. Clients often experience confusion, memory loss, and disorientation for a short period, particularly in the first 15 minutes after the procedure, as the anesthesia wears off and they recover from the induced seizure. This is a normal part of the recovery process.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

Condition: Opioid intoxication – The client's presentation of unresponsiveness, respiratory depression (RR 10/min), and miosis (pinpoint pupils) is consistent with opioid intoxication. Additionally, the presence of a needle in the antecubital space suggests recent intravenous drug use.

Finding: Pupil characteristics – Opioid intoxication commonly causes miosis (pinpoint pupils), which was observed in the client.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 min following the procedure?

Correct Answer is D

Explanation

A nurse is assisting with the care of client. Drag 1 condition and 1 finding to fill in each blank in the following sentences The client likely suffered from ____ as evidenced by ____ .

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

A nurse in a mental health facility caring for a client who expresses anxiety about exercising in the outdoor courtyard. The nurse promises to walk with the client in the courtyard each day. Which of the following ethical principles is the nurse demonstrating?

A nurse is collecting data from a client who is in renal failure. The nurse should identify that which of the following findings is a manifestation ofhyperkalemia?

A nurse is discussing home care concerns with the son of a client who has Alzheimer's disease. The son states, "I am so tired all the time, but Mom needs me." Which of the following responses should nurse make?

A nurse is preparing to administer haloperidol 0.5 mg by mouth to an older adult client. The amount available is haloperidol oral concentrate 2mg/mL. How many mL should the nurse administer? (Round the answer to the nearest hundredth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is assisting with the care of a client on their first prenatal visit. Which of the following screenings require follow up intervention?

A nurse is caring client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure?

A nurse is assisting with postmortem care for a client who was a devout follower of Islam. Which of the following actions should the nurse take?

A nurse is caring for a client who has schizophrenia and is taking an antipsychotic medication. Which of the following screening tools should the nurse use to identify tardive dyskinesia?

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