A nurse on a medical-surgical unit is caring for a client.
Which of the following findings indicates a need for follow-up by the nurse? Select all that apply.
Blood pressure
Potassium level
Respiratory rate
Urinary output
Heart rate
Temperature
Oxygen saturation
Skin assesses
Correct Answer : B,D
B. Potassium level: The normal potassium range is 3.5 to 5 mEq/L. The client's potassium level of 5.0 mEq/L is at the upper end of the normal range. While it is within the normal range, it is important to monitor it closely since elevated potassium levels can lead to cardiac dysrhythmias. Therefore, this finding indicates a need for follow-up by the nurse.
D. Urinary output: Urinary output is an important indicator of renal function and fluid balance. If the urinary output is significantly decreased or too low, it could indicate issues with kidney function or inadequate fluid intake. Monitoring urinary output is essential to assess the client's hydration status and kidney function. Therefore, this finding indicates a need for follow-up by the nurse.
Incorrect answers:
A. Blood pressure: Blood pressure is not indicated in the provided laboratory results. It is important to monitor blood pressure, but the information provided does not suggest any abnormality related to blood pressure.
C. Respiratory rate: Respiratory rate is not indicated in the provided laboratory results. It is important to monitor respiratory rate, but the information provided does not suggest any abnormality related to respiratory rate.
E. Heart rate: Heart rate is not indicated in the provided laboratory results. It is important to monitor heart rate, but the information provided does not suggest any abnormality related to heart rate.
F. Temperature: Temperature is not indicated in the provided laboratory results. It is important to monitor temperature, but the information provided does not suggest any abnormality related to temperature.
G. Oxygen saturation: Oxygen saturation is not indicated in the provided laboratory results. It is important to monitor oxygen saturation, but the information provided does not suggest any abnormality related to oxygen saturation.
H. Skin assessment: Skin assessment is not indicated in the provided laboratory results. It is important to assess the skin, but the information provided does not suggest any abnormality related to skin assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
No explanation
Correct Answer is C
Explanation
Choice A reason:
75 mL of greenish-yellow drainage should not be reported. This could be stomach contents or bile, which can be expected after surgery and might not be alarming.
Choice B reason:
150 mL of serosanguineous drainage should not be reported. Serosanguineous drainage is a mix of clear and slightly bloody fluid, which can be expected after surgery and may not be alarming.
Choice C reason:
100 mL of red drainage should be reported. After abdominal surgery, the drainage from an NG (nasogastric) tube is monitored to assess the client's condition and the status of their gastrointestinal system. Red drainage could indicate bleeding, which is a significant concern after surgery. The nurse should report this finding to the provider for further evaluation and intervention.
Choice D reason:
200 mL of brown drainage should not be reported. Brown drainage could also be indicative of old blood or digestive fluids, which might be expected after surgery and may not be alarming.
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