A nurse is caring for a client
A nurse is reviewing the client's electronic medical record. Which of the following findings requires follow-up?
Select all that apply.
Potassium level.
Temperature.
WBC count.
Breath sounds.
Blood pressure.
Correct Answer : B,C,D
B, C, and D. These findings require follow-up because they indicate possible complications of chemotherapy, such as infection, low blood cell counts, and lung damage.
Choice B is correct because a temperature of 38.6° C (101.5° F) is a sign of fever, which can indicate an infection. Chemotherapy can weaken the immune system and make the client more prone to infections.
Choice C is correct because a WBC count of 3,800/mm3 is below the normal range of 5,000 to 10,000/mm3 and indicates leukopenia, a condition of low white blood cells. Chemotherapy can cause leukopenia by damaging the bone marrow where blood cells are produced.
Choice D is correct because crackles heard at the bases of the lungs are abnormal breath sounds that can indicate fluid accumulation or inflammation in the lungs. Chemotherapy can cause lung damage by affecting the cells that line the airways or by triggering an immune response.
Choice A is wrong because a potassium level of 3.6 mEq/L is within the normal range of 3.5 to 5 mEq/L and does not require follow-up.
Choice E is wrong because a blood pressure of 114/56 mm Hg is within the normal range of less than 120/80 mm Hg and does not require follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This means that the client knows who they are, where they are, and what time it is. This indicates a high level of consciousness and a normal Glasgow coma scale (GCS) rating of 15.
Choice A is wrong because the client withdraws from pain.
This means that the client reacts to a painful stimulus by pulling away from it. This indicates a lower level of consciousness and a GCS rating of 4 for motor response.
Choice B is wrong because the client is unable to obey commands.
This means that the client does not follow simple instructions such as moving a limb or opening their eyes. This indicates a lower level of consciousness and a GCS rating of 1 or 2 for motor response.
Choice C is wrong because the client opens eyes to sound.
This means that the client does not open their eyes spontaneously, but only when they hear a loud noise. This indicates a lower level of consciousness and a GCS rating of 3 for eye opening.
The Glasgow coma scale is a clinical tool used to assess the level of consciousness of a person after a brain injury.
It consists of three tests: eye opening, verbal response, and motor response.
Each test has a score range from 1 to 6, with higher scores indicating higher levels of consciousness. The total score ranges from 3 to 15, with lower scores indicating higher risk of death.
Correct Answer is B
Explanation
Bradypnea is abnormally slow breathing, which can be a sign of life-threatening respiratory depression caused by morphine. Respiratory depression is the most serious adverse effect of morphine and can lead to coma and death if not treated promptly. Therefore, the nurse should monitor the child’s respiratory rate and oxygen saturation closely and be prepared to administer naloxone, an opioid antagonist, if needed.
Choice A is wrong because euphoria is a feeling of intense happiness or well-being that is a common side effect of morphine.
Euphoria is not a priority finding and does not indicate a serious complication of morphine.
Choice C is wrong because constipation is a common and chronic side effect of morphine that affects the gastrointestinal system.
Constipation can cause discomfort and complications such as bowel obstruction, but it is not a priority finding compared to respiratory depression.
Choice D is wrong because sedation is another common side effect of morphine that affects the central nervous system.
Sedation can impair the child’s level of consciousness and ability to respond to stimuli, but it is not as urgent as respiratory depression.
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