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A nurse is caring for a client in a long-term care facility.

Exhibits
Which of the following assessment findings require follow-up by the nurse? Select all that apply.

Vocal quality

Blood pressure

Albumin

BMI

Dentition

Bowel pattern

Lung sounds

Temperature

Secretions

Posture

Answer and Explanation

Correct Answer : A,D,F,G,H,I,J

A. Vocal quality – The client’s voice is hoarse and weak on Day 30, which may indicate dehydration, malnutrition, or an underlying respiratory issue.

B. Blood pressure – The client's blood pressure has slightly decreased but remains within a normal range, so it does not require immediate follow-up.

C. Albumin – Serum albumin levels are still within normal range.

D. BMI – The drop from 20 to 19 suggests unintentional weight loss, which could indicate malnutrition, inadequate intake, or an underlying illness.

E. Dentition –No difficulty in chewing reported.

F. Bowel pattern – The client has constipation for three days, which may require intervention to prevent complications like fecal impaction or discomfort.

G. Lung sounds – Diminished breath sounds at the bases may indicate fluid accumulation, atelectasis, or respiratory infection, requiring further evaluation.

H. Temperature – The client’s fever (38.1°C/100.6°F) suggests a possible infection and requires monitoring for underlying illness.

I. Secretions – Thick oral secretions may indicate dehydration, poor oral hygiene, or a swallowing issue, requiring follow-up to prevent aspiration.

J. Posture – The client’s slumped posture and fatigue could indicate weakness, nutritional deficiencies, or an underlying neurological or musculoskeletal problem.

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Correct Answer is D

Explanation

A. Bradypnea: Bradypnea (slow breathing) is not a typical late sign of hypoxia. Instead, clients with worsening hypoxia often develop tachypnea (rapid breathing) as the body tries to compensate for low oxygen levels.

B. Restlessness: Restlessness is an early sign of hypoxia, not a late one. It occurs due to inadequate oxygenation of the brain, leading to agitation and confusion.

C. Hypertension: Hypertension can be an early response to hypoxia as the body attempts to increase oxygen delivery. However, as hypoxia progresses, blood pressure may drop due to worsening oxygen deprivation.

D. Tachycardia: Tachycardia (increased heart rate) is a late sign of hypoxia. The heart compensates for low oxygen levels by increasing cardiac output. However, if untreated, hypoxia can progress to bradycardia and cardiac arrest.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

i. Clean the puncture site with antiseptic and allow it to dry helps reduce the risk of infection and ensures an accurate reading by preventing contamination.

ii. Wipe away the first drop of blood before collecting the sample is the best next step because the first drop may contain tissue fluid, which can affect glucose accuracy.

Incorrect answers:

Warming the client's hand before performing the fingerstick improves blood flow, making it easier to obtain an adequate sample, especially in clients with diabetes who may have impaired circulation.

Massage the finger gently from the base toward the tip before puncturing promotes blood flow but should be done carefully to avoid excess squeezing, which can lead to inaccurate results.

Ensure the client's hand is below heart level when obtaining the sample encourages blood flow, making collection easier.

Apply firm pressure to the site after obtaining the sample prevents excessive bleeding and helps close the puncture site.

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A nurse is caring for a client in a long-term care facility. Exhibits Which of the following assessment findings require follow-up by the nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is receiving oxygen therapy. Which of the following findings should the nurse identify as a late manifestation of hypoxia?

Correct Answer is D

Explanation

A nurse is caring for a client in the emergency department. Exhibits Complete the following sentence by using the list of options. When obtaining a capillary blood sample for glucose testing, the nurse should dropdown, and then dropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

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A nurse is caring for a client in a long-term care facility.

Exhibits
Which of the following assessment findings require follow-up by the nurse? Select all that apply.