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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Free Nursing Study Resources

Correct Answer is D

Explanation

A. A reddened area without induration is not a positive result.

B. A reddened area without induration is not considered positive.

C. An induration of 5 mm is positive only for high-risk groups (e.g., immunocompromised clients).

D. An induration measuring 10 mm is considered positive in most adults, indicating TB exposure.

A. Ranitidine B. Vitamin K C. Vitamin B12 D. Metoclopramide

Correct Answer is C

Explanation

A. Ranitidine: An H2 receptor blocker, typically used to reduce stomach acid, is unnecessary since the stomach has been removed.

B. Vitamin K: Although important for clotting, vitamin K absorption is not significantly affected by total gastrectomy.

C. Vitamin B12: Clients require lifelong vitamin B12 supplementation (usually via intramuscular injections) after total gastrectomy to prevent deficiency and associated complications such as anemia and neurological impairments.

D. Metoclopramide: A prokinetic agent used to enhance gastric motility, which is not relevant after total gastrectomy.

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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

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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.