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A nurse is caring for a 44-year-old client who was admitted with an elevated temperature and abdominal pain.
Exhibits

Select the top 4 client findings that requires immediate follow up.

Potassium 7.0 mEq/L (3.5 to 5 mEq/L)

WBC count 17,000/mm3 (Normal Finding: 5,000 to 10,000/mm3)

Crackles throughout lungs

Creatinine 3.0 mg/dL (0.5 to 1.3 mg/dL)

Abdomen rigid with decreased bowel sounds

Glucose 250 mg/dL

No dialysis for 24 hr

Hemoglobin 10 g/dL (12 to 18 g/dL) Nausea

Answer and Explanation

Correct Answer : A,B,C,H

A. Potassium 7.0 mEq/L (3.5 to 5 mEq/L): Elevated potassium levels (hyperkalemia) can cause life-threatening cardiac arrhythmias and are especially concerning in clients with chronic kidney disease who are at risk of renal complications. Immediate follow-up is crucial to prevent severe cardiac effects.

B. WBC count 17,000/mm³ (Normal Finding: 5,000 to 10,000/mm³): An elevated WBC count indicates an infection or inflammation, which is concerning given the client’s symptoms and temperature. This finding requires immediate follow-up to address potential infection.

C. Crackles throughout lungs: Crackles may indicate fluid overload or pulmonary edema, particularly in clients with chronic kidney disease. This could be a sign of worsening renal function or heart failure, which requires prompt attention.

H. No dialysis for 24 hr: Missing dialysis sessions in a client with stage IV chronic kidney disease can lead to dangerous fluid and electrolyte imbalances. This finding requires immediate action to prevent complications related to renal failure.

Explanation of Incorrect Options:

E. Creatinine 3.0 mg/dL (0.5 to 1.3 mg/dL): While elevated creatinine levels are concerning, the client’s history of chronic kidney disease means this level is expected to be higher. However, it is not as immediately critical as the other findings.

F. Abdomen rigid with decreased bowel sounds: This may suggest abdominal complications but is not as immediately critical as issues related to hyperkalemia or infection.

G. Glucose 250 mg/dL: Elevated glucose levels are concerning but less immediately critical compared to severe electrolyte imbalances and potential infections.

H. Hemoglobin 10 g/dL (12 to 18 g/dL): Anemia is a concern but is not as urgent as the immediate risks posed by elevated potassium, signs of infection, or missed dialysis.

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Correct Answer is D

Explanation

A. Pain severity is important to assess but is secondary to ensuring the client's airway is clear and unobstructed.
B. Wound drainage is relevant for detecting potential complications but is not as critical as ensuring airway patency.
C. Tissue integrity is important for wound healing but does not take precedence over checking the airway immediately after surgery.
D. Airway patency is the priority assessment because a partial laryngectomy involves the airway, and ensuring it is open and functioning is crucial for adequate breathing.

A. Paresthesia B. Paraplegia C. Quadriplegia D. Hemiplegia

Correct Answer is B

Explanation

A. Paresthesia, or abnormal sensation, can occur with spinal cord injuries but is not a primary type of disability specific to injury at T2-T3.
B. Paraplegia, or paralysis of the lower half of the body, is anticipated with a spinal cord injury at the T2-T3 level, affecting the thoracic region and below.
C. Quadriplegia, or paralysis of all four limbs, results from injuries at the cervical spinal cord levels, not the thoracic levels.
D. Hemiplegia, or paralysis on one side of the body, is typically associated with brain injuries or strokes, not spinal cord injuries at T2-T3.

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A nurse is caring for a 44-year-old client who was admitted with an elevated temperature and abdominal pain. Exhibits Select the top 4 client findings that requires immediate follow up.

Nursing Test Bank

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A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?

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Explanation

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A nurse is caring for a 44-year-old client who was admitted with an elevated temperature and abdominal pain.
Exhibits

Select the top 4 client findings that requires immediate follow up.