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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 A

Explanation

A. "Consume vitamin D supplements daily": This is correct as vitamin D is crucial for calcium absorption and bone health, which helps in preventing osteoporosis.
B. "Obtain an x-ray of your growth plate every 6 months": This is not necessary for osteoporosis prevention. Growth plates are relevant in children and adolescents, not in older adults.
C. "Decrease vitamin K in your diet": Vitamin K is important for bone health and should not be decreased. It plays a role in bone mineralization and should be included in a balanced diet.
D. "Engage in passive range-of-motion exercises": Active weight-bearing exercises are more beneficial for preventing osteoporosis. Passive range-of-motion exercises do not provide the same benefits for bone density and strength.

A. Ammonia 55 mcg/dL (10 to 80 mcg/dL) B. Platelets 60,000/mm³ (150,000 to 400,000/mm³) C. Aspartate aminotransferase 34 units/L (0 to 34 units/L) D. Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL)

Correct Answer is B

Explanation

A. Ammonia 55 mcg/dL (10 to 80 mcg/dL): This value is within the normal range and does not indicate an immediate concern for a liver biopsy.
B. Platelets 60,000/mm³ (150,000 to 400,000/mm³): This value is significantly below the normal range and indicates thrombocytopenia, which increases the risk of bleeding during a liver biopsy and should be reported to the provider.
C. Aspartate aminotransferase 34 units/L (0 to 34 units/L): This value is on the upper limit of normal and generally does not require reporting unless there are other clinical concerns.
D. Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL): This value is at the upper limit of normal and does not require reporting unless there are additional symptoms or concerns.

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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.

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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.