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A nurse on a medical-surgical unit is assisting in the care of a male client.
Exhibits
Which of the following findings indicate a need for follow-up by the nurse? Select all that apply.

Temperature

Heart rate

Skin findings

Respiratory rate

Oxygen saturation

Blood pressure

Urinary output

Answer and Explanation

Correct Answer : B,F,G

A. Temperature: The temperature remains stable and within normal limits. A postoperative temperature range of 36.3° C (97.3° F) to 36.4° C (97.5° F) is not indicative of infection or other complications at this time.

B. Heart rate: The heart rate has increased from 84/min to 104/min, indicating sinus tachycardia. This could be a compensatory response to decreased blood volume or another underlying issue, necessitating further assessment.

C. Skin findings: The skin findings are described as warm and dry, which is normal. No abnormalities are noted, so this does not require follow-up.

D. Respiratory rate: The respiratory rate has increased slightly to 24/min but is not significantly abnormal. This may not be a priority for follow-up unless other symptoms are present.

E. Oxygen saturation: The oxygen saturation is within normal limits (96% on room air), suggesting adequate oxygenation. No immediate concerns are evident based on this measurement.

F. Blood pressure: The blood pressure has dropped from 106/74 mm Hg to 88/54 mm Hg, indicating possible hypotension. This drop could signal hypovolemia or bleeding, requiring prompt follow-up to investigate the cause.

G. Urinary output: The urinary output of 110 mL over 6 hours is low, which might indicate dehydration or renal issues. Monitoring and addressing this finding are important to ensure adequate fluid balance and kidney function.

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Correct Answer is C

Explanation

A. Elevate the head of the bed 45° before starting the CPM device: This is not necessarily required and may not be appropriate based on the specific needs of the client or the setup of the CPM device.
B. Ensure the frame joint is in a flexed position before placing the leg onto the device: This is incorrect as the CPM device should be properly aligned with the joint's neutral position to avoid discomfort and ensure effective movement.
C. Ensure the knee joint is positioned over the CPM device frame joint: This is correct as proper alignment ensures that the device functions effectively and helps in the controlled movement of the knee joint.
D. Instruct the client to increase the degree of flexion as tolerated: This is incorrect as the degree of flexion should be adjusted according to the provider’s orders, not based on the client’s tolerance alone.

A. Primary health problem B. Admission vital signs from 1 week ago C. Scheduled times for dressing changes D. Number of family members who have visited E. Current medication prescriptions

Correct Answer is ["A","C","E"]

Explanation

A. Primary health problem: This is correct as it provides critical context for the client's current condition and the reason for the transfer.
B. Admission vital signs from 1 week ago: This is incorrect because recent vital signs are more relevant to the current status of the client; historical data from a week ago is less pertinent.
C. Scheduled times for dressing changes: This is correct as it is important for the receiving unit to know about ongoing care needs related to wound management.
D. Number of family members who have visited: This is incorrect as it does not pertain to the client's medical condition or immediate care needs.
E. Current medication prescriptions: This is correct as it is essential for the new care team to have information on the medications the client is currently taking to ensure continuity of care.

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A nurse on a medical-surgical unit is assisting in the care of a male client. Exhibits Which of the following findings indicate a need for follow-up by the nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following a total knee arthroplasty and using a continuous passive motion (CPM) device. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is ["A","C","E"]

Explanation

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A nurse on a medical-surgical unit is assisting in the care of a male client.
Exhibits
Which of the following findings indicate a need for follow-up by the nurse? Select all that apply.