A nurse is caring for a client.

Exhibits

The nurse is assessing the client.

Select the 4 findings that require immediate follow-up.

Heart rate

Sleep pattern

Hallucinations

skin turgor

Hygiene

Answer and Explanation

Correct Answer : A,C,D,E

A. Heart rate. The client has a heart rate of 120/min, which is tachycardia and may indicate dehydration, mania-related hyperactivity, or a response to poor nutritional status. This requires immediate follow-up to assess for cardiovascular strain or fluid imbalance.
B. Sleep pattern. While lack of sleep is concerning and a clear symptom of mania, it is a behavioral health issue that typically does not require immediate physiological intervention unless it leads to severe exhaustion or psychosis. It should be addressed, but is not the top priority.
C. Hallucinations. The client is responding to internal stimuli, indicating active psychosis, which poses a safety risk to the client and others. Hallucinations require immediate intervention to stabilize mental health and prevent harm.
D. Skin turgor. Poor skin turgor suggests dehydration, which is a priority physiological concern, especially when paired with tachycardia and failure to recall last food intake. This finding indicates the need for fluid and electrolyte evaluation and possible replacement.
E. Hygiene. The client's unclean appearance reflects self-neglect, a common feature of psychiatric decompensation, and may indicate inability to meet basic needs. This requires prompt attention to prevent complications like infection and assess for functional impairment, though it is secondary to life-threatening physiological or safety concerns.

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Correct Answer is C

Explanation

A. Decrease the maintenance infusion rate of IV fluid. Epidural anesthesia can cause hypotension, so IV fluids are often used to help maintain blood pressure. Reducing the fluid rate may increase the risk of hypotensive episodes.
B. Have protamine sulfate available at the bedside. Protamine sulfate is the antidote for heparin, not relevant to epidural anesthesia. It is not required in the management of epidural-related side effects.
C. Reposition the client side-to-side each hour. Frequent repositioning helps prevent pressure injuries, promotes fetal oxygenation, and encourages effective labor progression. It also aids in the distribution of the anesthetic agent.
D. Monitor the client for hypertension. Hypotension, not hypertension, is a common adverse effect of epidural anesthesia due to vasodilation and decreased peripheral resistance. Blood pressure should be monitored closely for drops.

A. Heart rate B. Temperature C. Lochia D. Hgb E. WBC count F. Fundal height

Correct Answer is ["A","B","C","E","F"]

Explanation

A. Heart rate. The client’s heart rate decreased from 110/min on postpartum day 3 to 78/min on day 5, returning to normal resting range, which suggests improvement in systemic inflammation or infection, and better overall hemodynamic stability.
B. Temperature. The temperature has decreased from 38.6° C (101.5° F) to 37.1° C (98.9° F), which is within normal limits. This reduction is a key indicator of resolving infection or inflammation, especially considering the earlier febrile response.
C. Lochia. Lochia has improved from a moderate, foul-smelling, dark brown discharge to a small amount of brownish-red lochia with no odor, which suggests infection resolution and appropriate progression of postpartum uterine involution.
D. Hgb. The client’s hemoglobin dropped from 11.1 g/dL to 10 g/dL, which is below the normal postpartum range. This is likely due to ongoing recovery, recent surgery, and fluid shifts, but it does not indicate improvement and may require continued monitoring.
E. WBC count. The WBC count normalized from a significantly elevated 33,000/mm³ to 10,000/mm³, which is within the normal reference range. This is a strong sign that the infection or inflammatory response is resolving.
F. Fundal height. The fundus has decreased from 1 cm above the umbilicus on day 3 to 4 cm below on day 5, which is consistent with normal involution of the uterus during the postpartum period and is a positive sign of recovery.

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Explanation

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A nurse is caring for a client.

Exhibits

The nurse is assessing the client.

Select the 4 findings that require immediate follow-up.