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 D

Explanation

A. Informing the client about pharmacological pain management contradicts her decision for a natural childbirth.

B. Encouraging family to leave during pain is unnecessary and may reduce support, which is essential for coping during labor.

C. Breathing techniques are helpful, but exhaling deeper than inhaling may not be appropriate for ventilation; rhythmic breathing is typically encouraged.

D. Hydrotherapy (such as warm baths or showers) is a natural pain management technique that can promote relaxation and decrease labor pain.

A. A client who requests to sit in the bedside chair while watching TV. B. A client who consumes all the food from their meal tray. C. A client who requests assistance to use the bedside commode. D. A client who has a prescription for compression stockings and did not receive them.

Correct Answer is D

Explanation

A. Requesting to sit in a chair is a normal activity and doesn't indicate a concern.

B. Consuming food from the meal tray is a normal activity and does not require reporting.

C. Requesting assistance to use the bedside commode is a normal activity and does not require reporting unless there is a change in condition.

D. Failing to receive prescribed compression stockings is an important issue because it can increase the risk of deep vein thrombosis (DVT), and it needs to be reported.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in the active phase of labor and has decided to have a natural childbirth. Which of the following pain management techniques should the nurse suggest?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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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.