A nurse is caring for a client.
Which of the following 6 findings indicate the client's condition is worsening and need to be reported to the health care provider?
Hydration status
Heart rate
Body aches
Oxygen saturation
Headache
Temperature
Bowel sounds
Emesis
Blood pressure
Correct Answer : A,B,E,F,H,I
Rationale:
A. Hydration status: Nausea, vomiting, and limited oral intake put the client at risk for dehydration, requiring monitoring and possible intervention.
B. Heart rate: Increased from 80/min at 1730 to 102/min at 2300, indicating possible systemic stress or dehydration.
E. Headache: Client reports a severe headache (7/10), which can indicate systemic worsening or complications.
F. Temperature: Rose to 39° C (102.2° F), showing worsening infection.
H. Emesis: Client vomited 230 mL, which can contribute to fluid and electrolyte imbalance.
I. Blood pressure: Increased from 118/72 mm Hg to 152/92 mm Hg, suggesting possible stress response, pain, or early complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
Rationale:
A. Client 3: The client is 4 days post–total hip replacement, ambulating well with assistance, and stable. This client is appropriate for discharge to free up beds.
B. Client 4: The client has COPD with a high fever and thick blood-tinged sputum, indicating acute illness that requires continued hospitalization.
C. Client 2: The client is preoperative for bariatric surgery, which can potentially be postponed or discharged preoperatively if stable, making them suitable for discharge in a mass casualty scenario.
D. Client 1: The client has ongoing chest pain with recent nitroglycerin use and cardiac monitoring, requiring continued inpatient care.
E. Client 5: The client is hypotensive and tachycardic due to dehydration, requiring ongoing IV fluids and monitoring, so discharge is unsafe.
Correct Answer is D
Explanation
Rationale:
A. Client concerns about meals should be addressed but do not require an incident report—these can be managed through dietary services or routine documentation.
B. Difficulty obtaining medication from the pharmacy is a systems issue, but it does not directly involve a client safety event and therefore does not require an incident report.
C. A client’s refusal of medication is their right and should be documented in the medical record, not reported as an incident.
D. Withholding a client’s scheduled medication constitutes a medication error/variance, which directly affects client safety and must be documented using an incident report.
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