A nurse is caring for a male client in the emergency department.
The nurse is reviewing the clients electronic medical records
Select the 4 findings that require immediate follow-up.
Upper arm and lower leg findings
Skin temperature
Blood pressure
Bowel sounds
Hgb
Heart rate
Correct Answer : A,C,E,F
Rationale:
A. Upper arm and lower leg findings: The presence of ecchymoses indicates impaired coagulation, which is common in chronic liver disease due to decreased clotting factor production. In the context of active bleeding (hematemesis), this is significant and needs immediate evaluation.
B. Skin temperature: Cool and dry skin, while concerning, is a nonspecific symptom. It may support a diagnosis of hypovolemia or shock, but on its own, it does not require the same urgent intervention as abnormal vital signs or lab results.
C. Blood pressure: A BP of 92/56 mm Hg indicates hypotension and suggests the client may be experiencing hypovolemic shock from gastrointestinal bleeding. This finding requires immediate intervention to prevent end-organ damage.
D. Bowel sounds: Bowel sounds auscultated in all four quadrants suggest that gastrointestinal motility is present. This is not a priority finding and does not indicate an urgent complication.
E. Hgb: A hemoglobin level of 7 g/dL is critically low and consistent with significant blood loss. This value requires immediate follow-up, likely including blood transfusion and identification of the bleeding source.
F. Heart rate: A heart rate of 118/min reflects a compensatory response to hypotension or blood loss. Tachycardia in this setting is a key sign of circulatory compromise and must be addressed immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Walk 30 min daily at a comfortable pace: While daily walking is beneficial, a comfortable pace may not provide enough cardiovascular benefit. Moderate-intensity aerobic activity is more effective in preventing coronary artery disease.
B. Limit saturated fat intake to 10% of total daily calories: Reducing saturated fat intake helps lower LDL cholesterol levels, a major contributor to atherosclerosis. This dietary modification is a key recommendation for coronary artery disease prevention.
C. Maintain a BMI of 30: A BMI of 30 indicates obesity, which is a significant risk factor for coronary artery disease. The goal should be to maintain a BMI under 25 to reduce cardiovascular risk.
D. Consume at least 2,000 mg of sodium per day: While 2,000 mg may seem moderate, most guidelines recommend keeping sodium intake below this level—often under 1,500 mg—to reduce hypertension and lower heart disease risk.
Correct Answer is A
Explanation
Rationale:
A. Place monitoring cords and tubes in a stockinette: Clients with latex allergies are at risk for serious reactions from contact with latex-containing equipment. Covering cords and tubing with a stockinette helps prevent direct skin exposure to latex, reducing the risk of an allergic reaction.
B. Schedule the client for the last surgery of the day: Clients with latex allergies should be scheduled as the first surgery of the day to minimize their exposure to airborne latex particles and reduce contamination from previously used equipment or surfaces.
C. Choose rubber injection ports for fluid administration: Rubber injection ports often contain latex, which can trigger severe allergic reactions. For clients with latex allergies, non-latex or latex-free alternatives must be used for all fluid and medication administration.
D. Have phenytoin IV readily available: Phenytoin is an anticonvulsant used to manage seizures and is not specifically indicated for treating allergic reactions. Epinephrine, antihistamines, and corticosteroids should be available in case of an anaphylactic reaction.
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