A nurse is caring for a client in the emergency department (ED).

Exhibits

Select the 4 assessment findings on day 2 that require immediate follow-up.

Heart rate

Oxygen saturation

Edema

Temperature

Urine color

Pedal pulses

Answer and Explanation

Correct Answer : A,C,E,F

A. Heart rate: The increased heart rate (108/min) may indicate a developing complication such as hypovolemia or pain. This requires monitoring as it could signal deteriorating status.

B. Oxygen saturation: The SpO₂ level is stable at 96%, which is within an acceptable range and does not indicate an immediate concern.

C. Edema: The increase in sacral and iliac region edema (2+) from day 1 to day 2 suggests worsening swelling and possible fluid accumulation, which could be affecting blood flow and leading to circulatory issues.

D. Temperature: The temperature remains within a normal range, so it does not require immediate intervention.

E. Urine color: Dark, reddish-brown urine suggests possible bleeding or rhabdomyolysis, both of which require immediate follow-up to prevent further complications and assess kidney function.

F. Pedal pulses: The change to 1+ pedal pulses bilaterally and the delayed capillary refill time (6 seconds) indicate reduced perfusion to the lower extremities, which may suggest compromised circulation or increased edema affecting blood flow.

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Correct Answer is D

Explanation

A. A protective environment is not necessary; Clostridium difficile requires contact precautions.

B. Alcohol-based hand sanitizers are ineffective against Clostridium difficile spores; handwashing with soap and water is essential.

C. Wearing a mask is not necessary as C. difficile is transmitted through spores that survive on surfaces.

D. Disinfecting equipment daily helps reduce the risk of C. difficile spore transmission within the environment.

A. Headache B. Hiccoughs C. Absence of urge to void D. Numbness in the legs

Correct Answer is A

Explanation

A. A headache is a common complication of spinal anesthesia, resulting from cerebrospinal fluid leakage at the puncture site.

B. Hiccoughs are not typically associated with spinal anesthesia complications.

C. An absence of urge to void may occur post-spinal anesthesia but is generally expected rather than a sign of complication.

D. Numbness in the legs is an anticipated effect post-spinal anesthesia, not necessarily indicating a complication.

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A nurse is caring for a client in the emergency department (ED). Exhibits Select the 4 assessment findings on day 2 that require immediate follow-up.

Nursing Test Bank

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A nurse is caring for a client in the emergency department (ED).

Exhibits

Select the 4 assessment findings on day 2 that require immediate follow-up.