A nurse is caring for a patient who has cirrhosis of the liver.
The patient’s vital signs are as follows: Heart rate 101/min, Temperature 36 C (96.9 F), Respiratory rate 24/min, Blood pressure 82/58 mm Hg, Oxygen saturation 92%. Which of the following assessment findings require immediate follow-up? Select all that apply.
Abdominal girth.
Blood pressure.
Heart rate.
Oxygen saturation.
Correct Answer : B,C,D
Choice A rationale
While monitoring abdominal girth can be important in patients with cirrhosis, especially those with ascites, it is not typically an assessment finding that requires immediate follow-up.
Choice B rationale
A blood pressure of 82/58 mm Hg is low and could indicate hypotension, which requires immediate follow-up.
Choice C rationale
A heart rate of 101/min is elevated and could indicate tachycardia, which requires immediate follow-up.
Choice D rationale
An oxygen saturation of 92% is lower than the normal range of 95% to 100%, indicating potential hypoxia, which requires immediate follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Constipation is a potential side effect of aripiprazole, but it is not typically a serious concern that would require notifying the provider.
Choice B rationale
Weight gain of 5 lb in 1 month could be a side effect of aripiprazole, but it is not typically a serious concern that would require notifying the provider.
Choice C rationale
Insomnia is a potential side effect of aripiprazole, but it is not typically a serious concern that would require notifying the provider.
Choice D rationale
Muscle stiffness could be a sign of a serious side effect of aripiprazole known as extrapyramidal symptoms. This could include conditions such as dystonia, akathisia, and Parkinsonism. If a patient experiences muscle stiffness while taking aripiprazole, the healthcare provider should be notified.
Correct Answer is A
Explanation
Choice A rationale
Cleaning the catheter after each use with soap and water is a crucial step in preventing infection during self-catheterization.
Choice B rationale
The angle at which the penis should be held during catheter insertion can vary, but a 30 to 45- degree angle is not typically recommended.
Choice C rationale
Performing catheterization when feeling the urge to void is not typically part of the instructions for clean intermittent self-catheterization.
Choice D rationale
Inflating the balloon when the urine flow stops is not a step in clean intermittent self- catheterization. This step is associated with indwelling catheters, not intermittent catheters.
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