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 A
Explanation
Choice A reason:
Measuring the client's blood pressure is appropriate. Assessing the client's blood pressure is a crucial initial step to determine the client's perfusion status and the impact of the bradycardia on their circulation. Sinus bradycardia can result in decreased cardiac output and compromised blood flow to various organs. Measuring the blood pressure helps the nurse evaluate the severity of the bradycardia and its potential effects on the client's overall condition.
Choice B Reason:
Administering atropine to the client is inappropriate. Atropine is a medication that can be used to increase heart rate in bradycardic situations. However, assessing blood pressure comes first to ensure that the blood pressure isn't critically low before administering medications.
Choice C reason:
Initiating IV fluid therapy for the client is inappropriate. Fluid therapy might be necessary to improve perfusion in certain cases, but assessing blood pressure should be done first to guide treatment decisions.
Choice D Reason:
Preparing the client for temporary pacing is inappropriate Temporary pacing might be required in severe cases of bradycardia, but again, assessing blood pressure takes priority to determine the urgency of intervention.
Correct Answer is C
Explanation
Choice A Reason:
Carvedilol is not the correct medication. Carvedilol is a beta-blocker used for heart conditions, and there is no specific need to withhold it following a CT scan with contrast media.
Choice B Reason:
Clopidogrel is not the correct medication. Clopidogrel is an antiplatelet medication, and there is no specific need to withhold it following a CT scan with contrast media.
Choice C Reason:
Metformin is the correct medication. The nurse should instruct the client to withhold metformin for 48 hours following a CT scan with contrast media. Contrast media used in imaging procedures can potentially cause kidney damage, and when combined with metformin, there is a risk of a serious condition called lactic acidosis. Withholding metformin for 48 hours after the procedure helps prevent this risk.
Choice D Reason:
Furosemide is not the correct medication. - Furosemide is a diuretic, and there is no specific need to withhold it following a CT scan with contrast media.
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