A nurse is caring for a client.
Exhibits
Select the 4 findings that require immediate follow-up.

Temperature

Breath sounds

Blood pressure

Heart rate

Swollen tongue

Urticaria

Answer and Explanation

Correct Answer : B,C,D,E

A.   The presence of wheezing indicates potential airway compromise, which is a significant concern in the context of an allergic reaction. Wheezing suggests bronchoconstriction and difficulty breathing, requiring immediate assessment and intervention to ensure adequate oxygenation.
B.   significant drop in blood pressure (hypotension) is a red flag for anaphylaxis, a severe and potentially life-threatening allergic reaction. Hypotension can lead to inadequate tissue perfusion and organ dysfunction, requiring immediate intervention with fluids and medications to stabilize blood pressure.
C.   rapid heart rate (tachycardia) can be a sign of an allergic reaction, particularly if accompanied by other symptoms such as hypotension or respiratory distress. Tachycardia may indicate the body's response to hypotension or increased sympathetic activity, and it warrants immediate follow-up to assess for shock or other complications.
D.   Swelling of the tongue (angioedema) can compromise the airway and lead to respiratory distress or obstruction. It is a concerning sign that requires immediate intervention to ensure the client's airway remains patent and adequate ventilation is maintained.
E.   A While an elevated temperature can indicate an inflammatory response, it is not typically the most concerning finding in an allergic reaction. In this case, the temperature elevation is mild and may be secondary to the allergic reaction, but it is not a critical priority for immediate follow-up compared to other findings.
F .Urticaria (hives) is a common manifestation of an allergic reaction and can be uncomfortable for the client. While it is important to address, it is typically not as immediately life-threatening as other symptoms such as wheezing or angioedema.

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Correct Answer is C

Explanation

C. Expelling air bubbles from the syringe before injecting the medication helps to ensure accurate dosing and prevent air embolism. The nurse should teach the client to flick the syringe with their finger to dislodge any air bubbles and then push the plunger slightly to expel the air before administering the medication.
A. Heparin is typically administered using a smaller gauge needle, such as a 25 to 27 gauge, and a shorter length, usually ranging from 3/8 inch to 5/8 inch, depending on the client's body habitus and the specific administration technique.
B. Massaging the injection site after withdrawing the needle can increase the risk of tissue damage, bruising, and hematoma formation.
D. The injection site for heparin administration is typically the abdomen, specifically the fatty tissue of the lower abdomen, avoiding the area around the umbilicus by at least 2 inches. However, specifying a measurement of 5.1 cm (2 in) is unnecessary and may confuse the client.

A. Invasion of privacy B. Battery C. Defamation D. Assault

Correct Answer is D

Explanation

D. Assault refers to the threat or apprehension of harmful or offensive contact with another person. In this scenario, the nurse's statement of threatening to administer medication by injection if the client doesn't comply with swallowing pills constitutes assault.
A. Invasion of privacy refers to the unauthorized intrusion into an individual's private affairs. While the nurse's statement may be inappropriate and unprofessional, it does not directly involve intruding into the client's private affairs.
B. The threat of administering medication by injection without consent is an act that could be considered harmful or offensive, and it's done to coerce compliance, which is not ethically or legally appropriate.
C. Defamation involves the communication of false statements about a person that harm the person's reputation. In this scenario, the nurse's statement does not involve making false statements about the client to harm their reputation.

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A nurse is caring for a client. Exhibits Select the 4 findings that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client how to self-administer heparin. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse manager overhears a nurse telling a client, "I will administer your medication by injection if you don't swallow your pills." The nurse manager should identify that the nurse is committing which of the following torts?

Correct Answer is D

Explanation

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A nurse is caring for a client.
Exhibits
Select the 4 findings that require immediate follow-up.