A nurse is caring for a client who has gastroenteritis and is reviewing the client's findings from two days ago and today. Which of the following findings require immediate follow-up?
The client is confused and appears weak.
The client's oral mucosa is dry and tongue is furrowed.
The client's temperature is 37.4° C (99.3° F).
The client's blood pressure is 90/58 mm Hg.
The Correct Answer is A
Choice A reason: Confusion and weakness are signs of dehydration and electrolyte imbalance, which can result from vomiting and diarrhea. These are serious complications that can affect the client's mental status, blood pressure, heart rate, and kidney function. The nurse should report these findings to the provider and monitor the client's vital signs and fluid status.
Choice B reason: Dry oral mucosa and furrowed tongue are also signs of dehydration, but they are less severe than confusion and weakness. The nurse should report these findings to the provider as well, but they are not the most urgent ones.
Choice C reason: A temperature of 37.4° C (99.3° F) is slightly elevated, but not indicative of a fever or infection. The nurse should document this finding, but it does not require immediate follow-up.
Choice D reason: A blood pressure of 90/58 mm Hg is low, but not hypotensive. The nurse should document this finding, but it does not require immediate follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Formula should not be changed to whole milk until the infant is 12 months old, as whole milk does not provide enough iron and other nutrients for the infant's growth and development. Whole milk can also cause intestinal bleeding and increase the risk of allergies in infants younger than 12 months.
Choice B reason: Formula that remains in the bottle should not be used for another feeding, as it can harbor bacteria and cause infection. Any formula that is not consumed within one hour of preparation or feeding should be discarded.
Choice C reason: If the infant turns away after taking most of the feeding, it is a sign that the infant is full and satisfied. The nurse should instruct the parents to stop the feeding and burp the infant. Forcing the infant to finish the bottle can cause overfeeding and vomiting.
Choice D reason: If the infant is gaining weight too rapidly, diluting the formula is not a safe or effective solution. Diluting the formula can cause water intoxication, electrolyte imbalance, and malnutrition in the infant. The nurse should advise the parents to consult with the infant's doctor about the appropriate amount and type of formula for the infant.
Correct Answer is A
Explanation
Choice A reason: Fried chicken is an acceptable choice for a client who is taking tranylcypromine, a monoamine oxidase inhibitor (MAOI). MAOIs can cause a hypertensive crisis if the client consumes foods that are high in tyramine, such as aged cheeses, cured meats, smoked fish, and fermented products. Fried chicken does not contain tyramine and is safe to eat.
Choice B reason: Salami is not an acceptable choice for a client who is taking tranylcypromine, as it is a cured meat that is high in tyramine. The nurse should advise the client to avoid salami and other similar foods, such as pepperoni, ham, bacon, and sausage.
Choice C reason: Smoked salmon is not an acceptable choice for a client who is taking tranylcypromine, as it is a smoked fish that is high in tyramine. The nurse should advise the client to avoid smoked salmon and other similar foods, such as herring, anchovies, and caviar.
Choice D reason: Cheddar cheese is not an acceptable choice for a client who is taking tranylcypromine, as it is an aged cheese that is high in tyramine. The nurse should advise the client to avoid cheddar cheese and other similar foods, such as blue cheese, Swiss cheese, and Parmesan cheese.
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