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A nurse is caring for a male client in the emergency department.

Exhibits

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

Answer and Explanation

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.

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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.

A. Fasting blood glucose 65 mg/dL (70 to 110 mg/dL) B. RBC count 6.3/μL (4.7 to 6.1/μL) C. BUN 24 mg/dL (10 to 20 mg/dL) D. Alkaline Phosphatase (ALP) 25 units/L (30 to 120 units/L)

Correct Answer is C

Explanation

Rationale:
A. Fasting blood glucose 65 mg/dL (70 to 110 mg/dL): While slightly below the normal range, this mild hypoglycemia is not a typical adverse effect of cyclosporine. Cyclosporine is more commonly associated with nephrotoxicity, hypertension, and increased infection risk rather than altering glucose levels significantly.

B. RBC count 6.3/μL (4.7 to 6.1/μL): This value is slightly elevated but not clinically concerning and is not a known adverse effect of cyclosporine. The medication typically affects white blood cells and kidney function more than red cell production.

C. BUN 24 mg/dL (10 to 20 mg/dL): An elevated BUN level may indicate reduced kidney function, which is a common adverse effect of cyclosporine. This immunosuppressant is nephrotoxic and requires close monitoring of renal function through BUN and creatinine levels.

D. Alkaline Phosphatase (ALP) 25 units/L (30 to 120 units/L): This ALP level is slightly below normal but not typically associated with cyclosporine use. Cyclosporine does not usually cause significant changes in ALP unless there is liver involvement, which is less common than kidney-related complications.

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A nurse is caring for a male client in the emergency department. Exhibits The nurse is reviewing the clients electronic medical records Select the 4 findings that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is scheduled for surgery and has a latex allergy. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is caring for a male client who has a new prescription for cyclosporine following a kidney transplant. Which of the following findings should the nurse identify as an adverse effect of this therapy?

Correct Answer is C

Explanation

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A nurse is caring for a male client in the emergency department.

Exhibits

The nurse is reviewing the clients electronic medical records
Select the 4 findings that require immediate follow-up.