Exhibits
A nurse is reviewing the medical record of a client who has COPD. Which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)
Platelet count
Sputum color
Temperature
Fluid intake
The Correct Answer is C
A. Platelet count is normal (175,000/mm3) and does not require reporting to the provider.
B. Sputum color: While thick green sputum might suggest infection, the nurse should first assess for other clinical signs, and it might not need immediate reporting unless there are other concerns, like a change in respiratory status.
C. Temperature (38°C / 100.4°F) is elevated, which could indicate an infection, such as a respiratory infection or exacerbation of COPD. This finding should be reported to the provider because fever in a client with COPD could lead to complications like pneumonia or exacerbation of symptoms.
D. Fluid intake of 2,200 mL/24 hr is within normal limits and does not need reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Neck is in a flexed position is correct. Torticollis (or wry neck) is a condition where the head is tilted to one side due to abnormal positioning of the neck muscles. The infant may exhibit a flexed or tilted neck, and there may be muscle tightness on one side of the neck.
B. Asymmetry of gluteal folds is incorrect. This finding is associated with hip dysplasia, not torticollis. Asymmetry of the folds could indicate a dislocated hip or other musculoskeletal issues.
C. Feet turn inward is incorrect. This finding suggests clubfoot rather than torticollis, a condition where the feet are turned inward and may require correctional intervention.
D. Frenulum connected to the tip of the tongue is incorrect. This describes a condition known as tongue-tie (ankyloglossia., which affects the tongue's movement and is unrelated to torticollis.
Correct Answer is B
Explanation
A. "Provide homeschooling for your child" is not a necessary instruction. Children with cystic fibrosis can attend school, and with appropriate care, they can often manage their condition and participate in normal activities.
B. "Have your child wear a medical identification wristband" is correct. A medical identification wristband is important for children with cystic fibrosis as it can provide crucial information in an emergency, such as their diagnosis and specific care needs.
C. "Ensure that your child does not receive the influenza vaccine annually" is incorrect. Children with cystic fibrosis are at higher risk for respiratory complications and should receive the influenza vaccine annually to help prevent infection and reduce the risk of exacerbations.
D. "Do not include your child when making decisions about treatment" is incorrect. Involving children in their treatment decisions, as appropriate for their age and understanding, is important for fostering autonomy and ensuring they feel empowered in managing their condition.
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