A nurse is caring for a client in the emergency department (ED).
Select the 4 assessment findings on day 2 that require immediate follow-up.
Heart rate
Oxygen saturation
Edema
Temperature
Urine color
Pedal pulses
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Option 1: Intracranial hemorrhage: The client’s recent fall, worsening headache, unilateral pupil dilation, right-sided weakness, and decreasing Glasgow Coma Scale (GCS) indicate a potential neurological injury, which is concerning for intracranial hemorrhage.
Option 2: Glasgow Coma Scale: The client's GCS has progressively declined (from 15 to 13), indicating a decrease in neurological function, which is critical in assessing intracranial pressure and risk for hemorrhage.
Correct Answer is C
Explanation
A. Widening pulse pressure is more indicative of increased intracranial pressure or septic shock, not hypovolemic shock.
B. Deep tendon reflexes are typically not increased in hypovolemic shock.
C. Increased heart rate is a compensatory response to hypovolemic shock as the body attempts to maintain cardiac output.
D. A pulse oximetry reading of 96% would not typically indicate hypovolemic shock; decreased oxygen saturation is more consistent with hypoxia.
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