A nurse is assisting with the care of a client

Exhibits

Select the 3 findings that require immediate follow-up.

Breath sounds at 1600

Temperature

Urticaria

Blood pressure at 1630

Report of dysphagia

Answer and Explanation

Correct Answer : C,D,E

A.   Bilateral breath sounds clear and present throughout at 1600 are normal findings and do not require immediate follow-up.
B.   The temperature at both 1600 (37.6°C) and 1630 (37.5°C) is slightly elevated but not critically high. It does not require immediate follow-up unless it worsens significantly or is accompanied by other concerning symptoms.
C.   Urticaria (hives) over the chest and trunk, along with itching and difficulty swallowing (dysphagia), are signs of an allergic reaction, which requires immediate follow-up and assessment.
D.   The blood pressure decreased to 78/52 mm Hg at 1630 from 110/58 mm Hg at 1600. This significant drop indicates hypotension and requires immediate follow-up.
E.   Difficulty swallowing (dysphagia) reported by the client suggests a potential airway compromise and requires immediate follow-up to assess the severity and intervene accordingly.

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Correct Answer is B

Explanation

A. Turning on the television can be distracting and hinder the client's ability to focus on the educational session.
B. Providing educational material at a 6th grade reading level ensures the information is accessible and understandable, enhancing the client's comprehension and adherence to the medication regimen.
C. Using technical language can confuse the client and make it difficult to understand important information about the medication.
D. Beginning with the least important information can cause the client to miss crucial details, so it is best to start with the most important points.

A. Intramuscular B. Enteral C. Intravenous D. Topical

Correct Answer is C

Explanation

Intramuscular administration provides relatively quick absorption but is slower than intravenous.
B. Enteral (oral) administration has the slowest absorption rate due to the process of digestion and first-pass metabolism in the liver.
C. Intravenous administration delivers the medication directly into the bloodstream, resulting in the fastest absorption and onset of action.
D. Topical administration is typically used for localized treatment and has a slower absorption rate compared to intravenous.

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A nurse is assisting with the care of a client Exhibits Select the 3 findings that require immediate follow-up.

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A nurse is assisting with the care of a client

Exhibits

Select the 3 findings that require immediate follow-up.