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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 B

Explanation

A: Location A is near the infant’s foot, specifically around the ankle. This area is where the posterior tibial or dorsalis pedis pulse would be palpated, not the femoral pulse. These pulses are important for assessing peripheral circulation but are not the primary site for evaluating coarctation of the aorta, which requires checking central pulses like the femoral.

B: Location B is at the upper inner thigh, near the groin, where the femoral artery passes close to the skin surface. This is the correct site for palpating the femoral pulse in an infant. In conditions like coarctation of the aorta, comparing the strength of the brachial and femoral pulses is crucial to detect differences in blood flow between the upper and lower body.

C: Location C is on the upper arm, near the shoulder area, which corresponds to the location for checking the brachial pulse. The brachial pulse is commonly used in infants to assess heart rate, especially during resuscitation efforts. However, it is not the site for assessing femoral pulse strength, which is needed when evaluating for coarctation of the aorta.

A. Request the family members leave the client's room B. Place dentures in the client's mouth. C. Remove the client's personal hair pieces. D. Lower the head of the client's bed.

Correct Answer is B

Explanation

A. Request the family members leave the client's room: Family members may choose to stay if they wish, and they should be allowed to participate or be present during postmortem care if it aligns with their emotional needs or cultural practices. Forcing them to leave is not appropriate unless required for specific procedures.

B. Place dentures in the client's mouth: Placing dentures helps maintain the natural shape and appearance of the face, offering a more familiar and comforting appearance for the family during viewing. This is an important step in preparing the body respectfully.

C. Remove the client's personal hair pieces: Hairpieces should be left in place unless the family or facility policy requests otherwise. Removing them without need can alter the client’s appearance and potentially distress the family.

D. Lower the head of the client's bed: The head of the bed should be elevated slightly, not lowered, to prevent blood from pooling in the head and face, which could cause discoloration and swelling before the family views the body.

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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

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Correct Answer is B

Explanation

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Correct Answer is B

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.