A nurse is reviewing the client's electronic medical record.

Exhibits

Which of the following findings require follow up? Select all that apply.

Blood pressure

Temperature

Potassium level

WBC count

Breath sounds

Answer and Explanation

Correct Answer : B,D,E

A. Blood pressure – The client's blood pressure of 114/56 mm Hg is within an acceptable range and does not indicate hypotension or hypertension.

B. Temperature – A temperature of 38.6°C (101.5°F) is indicative of fever, which is concerning in a client undergoing chemotherapy due to their increased risk of infection (febrile neutropenia). Prompt evaluation and intervention are necessary to prevent sepsis.

C. Potassium level – The client's potassium level of 3.6 mEq/L is within the normal range (3.5 to 5 mEq/L) and does not require immediate intervention.

D. WBC count – The client's WBC count has decreased to 3,800/mm³, which is below the normal range (5,000 to 10,000/mm³), indicating leukopenia. This places the client at a higher risk for infection, requiring close monitoring and potential interventions.

E. Breath sounds – The presence of crackles at the lung bases suggests possible pulmonary complications, such as fluid overload, infection (e.g., pneumonia), or early signs of acute respiratory distress syndrome (ARDS). This finding warrants further assessment and intervention.

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Correct Answer is A

Explanation

A. Privately interviewing the client is the first step in assessing the possibility of elder abuse and gathering detailed information.

B. Notifying risk management is necessary after abuse is confirmed or suspected, but it is not the first step.

C. Informing the transferring agency is not appropriate until further investigation.

D. Contacting the family may not be appropriate if they are suspected of abuse.

A. Read medication labels at least two times prior to administration. B. Avoid preparing medications for more than two clients at one time. C. Inform clients about the action of each medication prior to administration. D. Complete an incident report if a client vomits after taking a medication.

Correct Answer is B

Explanation

A. Read medication labels at least two times prior to administration: Labels should be read three times (when retrieving, preparing, and administering).

B. Avoid preparing medications for more than two clients at one time: Reduces the risk of medication errors by minimizing task-switching and confusion.

C. Inform clients about the action of each medication prior to administration: While educating clients is essential, it is not always required before every medication.

D. Complete an incident report if a client vomits after taking a medication: An incident report is typically required only for errors or adverse events.

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A nurse is reviewing the client's electronic medical record. Exhibits Which of the following findings require follow up? Select all that apply.

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A nurse is reviewing the client's electronic medical record. Exhibits Which of the following findings require follow up? Select all that apply.

A nurse is reviewing the client's electronic medical record.

Exhibits

Which of the following findings require follow up? Select all that apply.