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A nurse is caring for a client who presents to the emergency department.

Exhibits
A nurse is reviewing the client's record. Which of the following client findings indicate the need for further evaluation?
(Select All that Apply.)

Weight

Report of cough

Blood pressure

Travel history

Sputum characteristics

Temperature

Heart Rate

Answer and Explanation

Correct Answer : A,D,E,F,G

Based on the information provided, the nurse should consider the following client findings for further evaluation:

A. Weight: The client's weight loss of 5 pounds (2.26 kg) over the last week needs further evaluation as it could be indicative of an underlying health issue.

D. Travel history: The client's recent travel to South Africa and the presence of respiratory symptoms raises concerns about possible exposure to infectious diseases, including tuberculosis, which is more prevalent in certain regions. Further evaluation of the travel history is essential.

E. Sputum characteristics: The client's report of "blood-tinged sputum" is concerning and should be evaluated further to rule out potential serious respiratory conditions.

F. Temperature: The presence of a "low-grade fever" should be further evaluated to assess the possible infectious etiology of the client's symptoms.

G. Heart Rate: The heart rate should be assessed further as an elevated heart rate could indicate an underlying systemic infection or other health issues.

The following client findings do not necessarily indicate the need for further evaluation in this context:

B. Report of cough: The client's report of a cough is the primary reason for their presentation to the emergency department and will, of course, be further evaluated as part of the assessment.

C. Blood pressure: Though monitoring blood pressure is essential, the information provided does not indicate any specific concerns regarding the client's blood pressure at this point.

A comprehensive assessment and further evaluation are necessary to determine the underlying cause of the client's symptoms. The nurse should collaborate with other healthcare professionals to conduct appropriate diagnostic tests and investigations to establish a diagnosis and provide appropriate care.

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Correct Answer is C

Explanation

A. Incorrect. While it's important to maintain social interaction with the client, avoiding excessive conversation during feeding is recommended. Distractions can interfere with the client's ability to focus on swallowing and increase the risk of aspiration.

B. Incorrect.Coughing is a natural reflex that helps to clear the airway of any material that may have been aspirated. Discouraging coughing could potentially lead to a more serious problem.

C. Correct.Sitting at or below the client's eye level provides a clearer view of the food and helps the client maintain control over their swallowing. This can reduce the risk of aspiration.

D. Incorrect.Lifting the chin can actually increase the risk of aspiration by narrowing the opening to the trachea (windpipe). It's generally recommended to avoid lifting the chin during swallowing.

A. Leaving a nasogastric tube clamped after administering oral medication B. Placing a yellow bracelet on a client who is at risk for falls C. Administering potassium via IV bolus D. Documenting communication with a provider in the progress notes of the client's medical record

Correct Answer is C

Explanation

A. Incorrect. Leaving a nasogastric tube clamped after administering oral medication is a mistake, but it may not necessarily be considered malpractice if it doesn't result in harm or negligence.
B. Incorrect. Placing a yellow bracelet on a client at risk for falls is a safety measure, and it's not an example of malpractice.
C. Correct. Administering potassium via IV bolus can be dangerous and is considered malpractice if not done properly. Rapid administration of potassium via IV bolus can lead to serious cardiac complications.
D. Incorrect. Documenting communication with a provider in the progress notes of the client's medical record is a standard practice and not an example of malpractice.

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A nurse is caring for a client who presents to the emergency department. Exhibits A nurse is reviewing the client's record. Which of the following client findings indicate the need for further evaluation? (Select All that Apply.)

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A nurse is caring for a client who presents to the emergency department.

Exhibits
A nurse is reviewing the client's record. Which of the following client findings indicate the need for further evaluation?
(Select All that Apply.)