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A nurse is assisting with the care of a client.

A nurse is reviewing the client's electronic medical record. Which of the following findings on day 7 require further action? Select all that apply.

Weight

Potassium

Pedal pulses

Temperature

Orientation

Chest x-ray

Urine output

Answer and Explanation

Correct Answer : A,C,F,G

Weight: The client has gained over 1 kg (about 2.2 lb) within a week, suggesting fluid retention. In combination with crackles, edema, and cardiomegaly, this weight gain indicates worsening heart failure and requires prompt intervention to manage fluid overload.
Potassium: A potassium level of 3.5 mEq/L is at the lower limit of normal. While it should be monitored, it does not independently demand immediate action unless it trends lower or the client shows symptoms of hypokalemia.
Pedal pulses: Pedal pulses have decreased from 2+ to 1+, and the extremities are now cool. These changes suggest compromised peripheral circulation, likely related to decreased cardiac output, and warrant further assessment and management.
Temperature: The client’s temperature is within the normal range. There are no signs of fever or hypothermia, so this finding does not require immediate action based on the current clinical data.
Orientation: The client remains alert and oriented, with no noted decline in mental status. Therefore, orientation findings are stable and do not necessitate further immediate intervention.
Chest x-ray: The presence of cardiomegaly on chest x-ray suggests worsening heart failure or fluid overload. This finding is significant and requires timely medical evaluation and management to prevent further cardiac decompensation.
Urine output: The client’s urine output has drastically decreased from 520 mL/hr to 160 mL in 8 hours, indicating impaired renal perfusion or acute kidney injury. This is a critical finding and requires immediate provider notification and intervention.

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Correct Answer is C

Explanation

A. Urinary catheter: A urinary catheter is not routinely required for infants with a spica cast. Unless there are specific urinary retention issues or surgical complications, normal voiding is expected, and a catheter would introduce unnecessary risk for infection.

B. Wound vac: A wound vac is used for complex wound management involving significant drainage or delayed healing. Infants with a spica cast typically do not have open wounds that necessitate negative pressure wound therapy, making this equipment unnecessary for discharge.

C. Car seat: A special car seat or car bed is necessary for safe transportation of an infant in a spica cast, as standard car seats cannot accommodate the wide leg positioning. Proper fitting ensures both safety and compliance with transportation regulations during discharge.

D. Feeding pump: A feeding pump is typically used for clients requiring continuous enteral feeding. Unless the infant has a separate feeding disorder or gastrointestinal complication, feeding by mouth is expected, and a feeding pump would not be standard discharge equipment.

A. Auscultate the client's lung sounds B. Check the client's weight. C. Check the client's apical pulse. D. Obtain the client's oxygen saturation

Correct Answer is C

Explanation

A. Auscultate the client's lung sounds: While lung sounds are important to assess in clients with heart failure, auscultating lung sounds is not directly required before administering digoxin. The immediate concern with digoxin is its effect on heart rate and rhythm.

B. Check the client's weight: Monitoring weight is important in heart failure management to assess fluid retention, but weight measurement is not necessary immediately prior to administering a dose of digoxin.

C. Check the client's apical pulse: Before giving digoxin, it is critical to assess the client's apical pulse for one full minute. If the pulse is below a specified rate (60 beats/min for adults), the dose may need to be withheld and the provider notified due to the risk of digoxin-induced bradycardia.

D. Obtain the client's oxygen saturation: Oxygen saturation is important in evaluating respiratory function, but it is not a priority action before administering digoxin. The primary safety check is heart rate assessment.

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A nurse is assisting with the care of a client. A nurse is reviewing the client's electronic medical record. Which of the following findings on day 7 require further action? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the discharge planning of an infant who has a spica cast. Which of the following equipment needs should the nurse identify for discharge?

Correct Answer is C

Explanation

A nurse is preparing to administer a dose of digoxin to a client who is experiencing heart failure. Which of the following actions should the take prior to administering this medication?

Correct Answer is C

Explanation

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A nurse is assisting with the care of a client.

A nurse is reviewing the client's electronic medical record. Which of the following findings on day 7 require further action? Select all that apply.