A nurse is assisting in the care of an older adult client who was admitted from a long-term care facility.

Admission Assessment 1400:

Client's history includes cigarette smoking for 50 years but quit 3 years ago, Parkinson's disease, and anxiety. Yesterday, client reported "feeling bad." Client is alert and oriented to self, reports upper chest discomfort, and is coughing up thick clear sputum.

Select the 3 findings that require immediate follow-up.

Choice A rationale:

Using isopropyl alcohol to clean hearing aids is not recommended. Isopropyl alcohol can damage the hearing aid components, especially the plastic parts. It is essential to use cleaning solutions specifically designed for hearing aids to avoid damaging them. Including this statement indicates a misunderstanding of proper hearing aid care.

Choice B rationale:

Replacing the batteries every 2 weeks is a standard recommendation for hearing aid users. Hearing aid batteries typically last 1 to 2 weeks, depending on usage. Regular battery replacement ensures the hearing aids continue to function optimally. This statement demonstrates an understanding of the basic care required for behind-the-ear hearing aids.

Choice C rationale:

Cleaning the ear with cotton swabs before inserting hearing aids is not advisable. Cotton swabs can push earwax further into the ear canal, leading to impaction. Excessive earwax can interfere with hearing aid function. Instead, clients should be encouraged to clean the outer parts of the hearing aids and avoid inserting any objects, including cotton swabs, into the ear canal.

Choice D rationale:

Disconnecting the battery when removing hearing aids is the correct practice. By disconnecting the battery, the client ensures that the hearing aids are turned off, preserving battery life and preventing unnecessary drainage. This statement indicates an understanding of proper hearing aid care and demonstrates the client's ability to maintain the device effectively.

A. A client who has cellulitis and is receiving oral antibiotics every 8 hr has a mild to moderate infection that can be managed at home with proper wound care and medication adherence. The client does not require hospitalization unless there are signs of systemic infection or complications.

B. A client who is postoperative following an upper endoscopy procedure and is alert but does not have a gag reflex has a high risk of aspiration and airway obstruction due to impaired swallowing function. The client requires close monitoring and intervention until the gag reflex returns, which can take several hours or longer depending on the type and amount of anesthesia used.

C. A mother and their newborn 12 hr postdelivery have not completed the minimum recommended stay of 24 to 48 hours for uncomplicated vaginal deliveries or 72 to 96 hours for cesarean deliveries, according to the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. The mother and their newborn require assessment, education, support, and follow-up care to ensure their health and well-being.

D. A client who has lower extremity weakness and is newly admitted for observation has an undiagnosed condition that could indicate a serious neurological or vascular problem, such as stroke, spinal cord injury, or peripheral artery disease. The client requires diagnostic testing, evaluation, treatment, and rehabilitation to prevent further deterioration or complications.