A nurse is caring for a client who presents to the emergency department.
(Select All that Apply.)
Weight
Report of cough
Blood pressure
Travel history
Sputum characteristics
Temperature
Heart Rate
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. Furosemide is a diuretic that promotes the excretion of excess fluid and electrolytes. Weight loss is a direct outcome of diuresis and indicates the effectiveness of furosemide in reducing fluid volume excess.
B. Increased blood pressure is not an expected outcome of furosemide administration.
Furosemide is commonly used to reduce blood pressure in clients with fluid volume excess.
C. Decreased pain and decreased inflammation are not direct outcomes of furosemide administration.
Correct Answer is A
Explanation
A. Correct. Acetaminophen can be taken concurrently with enoxaparin without significant interactions or increased bleeding risk.
B. Incorrect. Ibuprofen and other nonsteroidal anti-inflammatory drugs (NSAIDs) should be used with caution in combination with anticoagulants due to an increased risk of bleeding.
C. Incorrect. Naproxen sodium, like other NSAIDs, should be used cautiously with anticoagulants due to potential interactions and bleeding risk.
D. Incorrect. Aspirin is an anticoagulant itself and can increase the risk of bleeding when taken with enoxaparin.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.