Click to highlight the findings that require immediate follow-up. (Select all that apply)
Respiratory rate 11/min
SpO2 > 94% on room air
Lungs clear to auscultation
Reports pain worsening in right forearm.
States right hand is “tingly.”
Able to move fingers
The Correct Answer is ["D","E"]
Choice A reason: A respiratory rate of 11/min is slightly below normal (12-20/min) but not immediately concerning in a stable elderly client without respiratory distress. It warrants monitoring but does not require urgent follow-up compared to neurological or musculoskeletal symptoms.
Choice B reason: SpO2 > 94% on room air is normal, indicating adequate oxygenation. This finding does not suggest respiratory compromise, so it does not require immediate follow-up, aligning with expected respiratory status in a stable client.
Choice C reason: Clear lung auscultation is a normal finding, indicating no airway obstruction or fluid. It does not suggest respiratory pathology, so it does not require immediate follow-up, reflecting stable pulmonary function in the client’s assessment.
Choice D reason: Worsening forearm pain after a fall suggests potential fracture, compartment syndrome, or nerve injury, especially in an elderly client. This escalating symptom requires immediate imaging and evaluation to prevent complications like tissue damage, making it critical for follow-up.
Choice E reason: Tingling in the right hand indicates possible nerve compression or injury, such as radial nerve damage from a fall. This neurological symptom demands urgent assessment to prevent permanent impairment, making it a priority for immediate follow-up.
Choice F reason: Ability to move fingers is a positive finding, suggesting some preserved motor function. While reassuring, it does not negate the need to address worsening pain and tingling, so it does not require immediate follow-up compared to other symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Monitoring neurovascular status every 12 hours is too infrequent; hourly checks are needed in skeletal traction to detect compromised circulation or nerve damage early. Assuming 12-hour intervals risks delayed detection, potentially leading to ischemia or permanent injury, critical to avoid in children with femur fractures.
Choice B reason: Educating guardians about pin site care before discharge ensures proper home management, preventing infections at traction pin sites, common in skeletal traction. This education is critical for continuity of care, reducing complications like osteomyelitis, and supporting recovery in children with femur fractures managed with traction.
Choice C reason: Assessing pain every 8 hours is inadequate for a child in traction, where pain can indicate complications; 4-hour or as-needed checks are standard. Assuming 8-hour intervals risks delayed pain management, potentially worsening comfort and recovery, critical for effective care in pediatric fracture patients.
Choice D reason: Lifting traction weights during repositioning disrupts alignment, risking fracture displacement or pain. Weights must remain constant. Assuming lifting is appropriate risks compromising treatment efficacy, delaying healing, and increasing complications, critical to avoid in maintaining proper traction for femur fracture recovery in children.
Correct Answer is B
Explanation
Choice A reason: Preeclampsia is not a contraindication for misoprostol; it may be used cautiously for labor induction in such cases under close monitoring. Transverse lie is a contraindication. Assuming preeclampsia contraindicates misoprostol risks unnecessary avoidance, potentially delaying necessary induction, critical for maternal and fetal safety in labor management.
Choice B reason: Transverse fetal lie is a contraindication for misoprostol, as it increases risks of uterine rupture or cord prolapse during labor induction due to improper fetal positioning. Cesarean delivery is preferred. Recognizing this prevents complications, ensuring maternal and fetal safety, critical in labor induction planning for malpresented fetuses.
Choice C reason: Intrauterine growth restriction is not an absolute contraindication for misoprostol; it may be used with caution if induction is indicated. Transverse lie is a clearer contraindication. Assuming restriction contraindicates risks delaying induction, potentially compromising fetal well-being, critical for timely labor management in growth-restricted pregnancies.
Choice D reason: Postterm pregnancy is an indication, not a contraindication, for misoprostol to induce labor and prevent fetal risks. Transverse lie is the contraindication. Assuming postterm contraindicates misoprostol risks delaying necessary induction, increasing risks like stillbirth, critical for ensuring safe delivery in prolonged pregnancies.
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