A nurse is caring for a client

Exhibits

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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

This is because the Glasgow Coma Scale (GCS) is a tool to assess the level of consciousness and neurological status of a client who has a closed head injury. The GCS score can help guide the priority of interventions and the need for further diagnostic tests.
Choice A is wrong because an MRI of the brain is not the first action to take for a client who has a closed head injury. An MRI may be indicated later to evaluate the extent of brain damage, but it is not an emergency procedure.
Choice B is wrong because mannitol IV bolus is a medication that reduces intracranial pressure (ICP) by drawing fluid out of the brain tissue. However, mannitol should not be administered before confirming the presence and degree of increased ICP, which can be done by measuring the GCS score and other vital signs.
Choice D is wrong because inserting an indwelling urinary catheter for the client is not the first action to take for a client who has a closed head injury. A urinary catheter may be needed to monitor fluid balance and renal function, but it is not an urgent intervention.

A. Use gestures to convey meaning. B. Pause in the middle of sentences. C. Speak slowly when talking to the interpreter. D. Establish eye contact & rapport with the client

Correct Answer is D

Explanation

This is because the nurse should establish eye contact and rapport with the client, not the interpreter, and show respect for the client’s culture and autonomy. The nurse should also use simple and clear language, avoid jargon and slang, and speak in short sentences.

Choice A is wrong because using gestures to convey meaning can be confusing or offensive to some cultures. The nurse should avoid relying on nonverbal communication and ask the interpreter for clarification if needed.

Choice B is wrong because pausing in the middle of sentences can disrupt the flow of communication and make it harder for the interpreter to translate accurately. The nurse should pause at the end of each complete thought or sentence to allow the interpreter to relay the information.

Choice C is wrong because speaking slowly when talking to the interpreter can imply that the interpreter is incompetent or unintelligent. The nurse should speak at a normal pace and tone, and allow enough time for the interpreter to translate.

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A nurse is caring for a client Exhibits A nurse is reviewing the client's electronic medical record. Which of the following findings requires follow-up? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a client who has a closed head injury. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is providing discharge teaching about home care of a surgical incision to a client who speaks a different language from the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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A nurse is caring for a client

Exhibits

A nurse is reviewing the client's electronic medical record. Which of the following findings requires follow-up?

Select all that apply.