A nurse is assisting with the care of a client.

Select the 3 findings that require immediate follow up

Heart rate

Pedal pulses

Breath sounds

Abdominal dressing

Respiratory rate

Oxygen saturation

Answer and Explanation

Correct Answer : A,D,E

A. Heart rate: The increase from 88/min to 110/min indicates tachycardia, which can be an early sign of hypovolemia, infection, or sepsis. When combined with hypotension and fever, this finding suggests possible postoperative complications requiring urgent evaluation.

B. Pedal pulses: Bilateral pedal pulses remain 2+, indicating adequate peripheral perfusion at this time. This finding is stable and does not suggest acute circulatory compromise requiring immediate follow-up.

C. Breath sounds: Breath sounds are clear and unchanged from admission, suggesting no current pulmonary complication such as atelectasis or pneumonia. This finding does not indicate an urgent problem.

D. Abdominal dressing: A sudden increase to a large amount of serosanguinous drainage after the client felt something “pop” raises concern for wound dehiscence or possible evisceration. This is a surgical emergency requiring immediate assessment and intervention.

E. Respiratory rate: The respiratory rate has increased from 18/min to 24/min, indicating tachypnea. This may reflect pain, infection, or developing sepsis and warrants prompt follow-up in the postoperative client.

F. Oxygen saturation: Oxygen saturation remains within an acceptable range at 95% on room air. Although it should continue to be monitored, it does not currently indicate acute respiratory compromise.

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Free Nursing Study Resources

Correct Answer is ["A","C","G","H"]

Explanation

A. Witnessing the death of their parents and sibling: Experiencing such severe trauma places the client at high risk for post-traumatic stress disorder (PTSD) and complicated grief. Immediate follow-up is necessary to assess emotional safety and provide appropriate mental health interventions.

B. Attends school regularly: Regular school attendance is a positive sign of functioning and does not require immediate follow-up. It indicates that the client maintains some level of daily routine and social engagement.

C. Client experiences nightmares: Nightmares following trauma can indicate PTSD or acute stress reaction. These symptoms warrant prompt assessment and intervention to prevent worsening sleep disturbances, anxiety, or functional impairment.

D. Blood pressure 122/80 mm Hg: This is within normal limits for a 16-year-old and does not require immediate follow-up. It is not indicative of acute physical risk.

E. Heart rate 99/min: While slightly elevated, this heart rate is within a mild range of normal for adolescents under stress and does not require immediate follow-up unless accompanied by other acute symptoms.

F. Startles easily during thunderstorms: A mild startle response, especially with a prior fear of storms, is not an urgent concern. While it may relate to trauma, it is not immediately dangerous or requiring urgent follow-up.

G. Friend reporting client is not themselves: Changes in behavior observed by peers can indicate worsening mental health or risk of self-harm. Immediate follow-up is important to evaluate mood, coping, and safety.

H. Smoking marijuana to clear their mind: Self-medicating with substances is a significant safety concern, particularly in adolescents coping with trauma. Immediate follow-up is required to assess for substance use disorder and potential harm to mental and physical health.

A. Monitor urine for protein. B. Obtain a nasopharyngeal swab C. Request an x-ray of the neck. D. Administer fluconazole

Correct Answer is C

Explanation

A. Monitor urine for protein: Proteinuria is unrelated to epiglottitis and does not provide useful information for assessing airway compromise. This intervention is not indicated for this condition.

B. Obtain a nasopharyngeal swab: Swabbing the throat can trigger gagging or laryngospasm, which may cause complete airway obstruction in a child with epiglottitis. Invasive procedures should be avoided until the airway is secured.

C. Request an x-ray of the neck: A lateral neck x-ray can help confirm the diagnosis of epiglottitis by showing a swollen epiglottis ("thumb sign"). Imaging is useful when performed carefully in a controlled environment.

D. Administer fluconazole: Fluconazole is an antifungal medication and is not indicated for bacterial epiglottitis, which is typically caused by Haemophilus influenzae type b or other bacteria.

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

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of client in a clinic. Based on the information in the client's medical record, which of the following findings require immediate follow-up? Select the 4 findings that require immediate follow-up by the nurse.

Correct Answer is ["A","C","G","H"]

Explanation

A nurse is assisting with the care of a preschooler who has epiglottitis. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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A nurse is assisting with the care of a client.

Select the 3 findings that require immediate follow up