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 C
Explanation
Choice A reason:
"will keep my left arm flexed at the elbow as much as possible": This statement is incorrect because after a mastectomy, it's important to promote full range of motion in the affected arm to prevent complications like contractures and lymphedema.
Choice B reason:
“will have to wait 2 months before additional saline can be added to my breast expander" Typically, the process of adding saline to a breast expander begins much sooner, often within a few weeks after surgery, depending on the individual’s healing progress and the surgeon’s protocol.
Choice C reason:
"should expect less than 25 ml of secretions per day in the drainage devices":After a mastectomy, drainage devices are often placed to prevent fluid accumulation. The client should be aware that once the drainage decreases to less than 25 ml per day, it may be an indication that the drain can be removed. This shows an understanding of what to monitor postoperatively.
Choice D reason:
"will perform strength-building arm exercises using a 15-pound weight": This statement is not appropriate, especially shortly after surgery. Gradual and gentle strength-building exercises are recommended, and using a 15-pound weight could be too strenuous and potentially harmful.
Correct Answer is A
Explanation
Choice A Reason:
"I should use salt sparingly while cooking. “Response A indicates the client's understanding of the dietary teaching. Using salt sparingly while cooking is consistent with a low-sodium diet. It shows that the client recognizes the importance of reducing sodium intake to adhere to the prescribed dietary restrictions.
Choice B Reason:
"I can use baking soda when I bake" - Baking soda contains sodium and is not typically recommended for someone on a low-sodium diet.
Choice C Reason:
"I should use canned instead of frozen vegetables" - Canned vegetables often contain added sodium for preservation, so choosing fresh or frozen vegetables without added salt is a better option for a low-sodium diet.
Choice D Reason:
"I can season my foods with lemon juice" - Lemon juice is a suitable alternative to adding sodium for flavour, and this statement shows the client's understanding of using low-sodium seasoning options.
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