A nurse is caring for a client who has a fractured right femur.
Select the 4 findings on day 2 that require immediate follow-up.
Pedal pulses
Breath sounds
Heart rate
Movement of right foot
Respiratory rate
Pulse oximetry
Correct Answer : B,C,E,F
A. While it's important to assess pedal pulses regularly, there is no indication in the scenario that the pedal pulses are abnormal or require immediate follow-up. The description mentions bilateral pedal pulses being present and intact throughout both days, suggesting no acute issues with peripheral circulation.
B. Crackles heard at the bases indicate possible pulmonary complications such as atelectasis or pneumonia, requiring further assessment and intervention.
C. A heart rate of 112/min indicates tachycardia, which could be a sign of pain, anxiety, or underlying cardiovascular issues. Further evaluation is needed to determine the cause.
D. The scenario states that the movement and sensation of the right foot are intact, with warm skin and no change in pigmentation. There are no signs of compromised neurovascular status in the right foot based on the provided information, so immediate follow-up for this finding is not necessary.
E. A respiratory rate of 28/min is elevated, suggesting respiratory distress or inadequate ventilation. Prompt assessment and intervention are necessary to address any respiratory issues.
F. A pulse oximetry reading of 88% on room air indicates hypoxemia, which requires immediate attention to ensure adequate oxygenation. Further assessment and intervention are needed to improve oxygen saturation levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Fever is a common manifestation of bacterial pneumonia, as it indicates the body's immune response to infection. Other typical symptoms include cough, shortness of breath, chest pain, and sputum production.
B. Drooling is not typically associated with bacterial pneumonia but may occur in conditions such as epiglottitis or aspiration pneumonia.
C. Tinnitus is not a characteristic manifestation of bacterial pneumonia but may occur with other conditions affecting the ear.
D. Steatorrhea refers to fatty stools and is not associated with pneumonia.
Correct Answer is D
Explanation
A. Chronic kidney disease often results in metabolic acidosis, leading to decreased bicarbonate levels rather than increased.
B. Chronic kidney disease commonly leads to hyperphosphatemia and hypocalcemia due to impaired renal excretion of phosphate and decreased activation of vitamin D, resulting in decreased calcium levels.
C. Chronic kidney disease often results in anemia due to decreased production of erythropoietin, leading to decreased hemoglobin levels rather than increased.
D. Increased creatinine levels are indicative of impaired renal function, a hallmark of chronic kidney disease.
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