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. Wipe any excess medication from the inner canthus outward: This is the correct approach. When administering ophthalmic ointment, the nurse should wipe away any excess from the inner canthus to the outer canthus to prevent contamination of the unaffected eye and to avoid spreading the infection.
B. Instruct guardian to apply erythromycin ophthalmic ointment every morning for 14 days.: This is incorrect because the child has been prescribed bacitracin ophthalmic ointment, not erythromycin. The nurse should instruct the guardian to use the prescribed medication as directed.
C. Gently massage the eyelid to facilitate absorption of the medication.: Massaging the eyelid is unnecessary and could lead to irritation or injury. The medication should be allowed to be absorbed naturally without additional manipulation.
D. Place an occlusive dressing on the affected eye to prevent the spread of infection.: An occlusive dressing is not recommended as it may cause increased irritation or pressure on the eye. The best practice is to maintain proper hygiene and follow the prescribed medication regimen.
Correct Answer is A
Explanation
A. Apply an ice pack to the affected extremity for 20 min every 2 hr.: Applying ice to the affected extremity can help reduce inflammation and discomfort associated with deep-vein thrombosis (DVT). This method is often recommended to decrease swelling and prevent further complications.
B. Massage the affected extremity every 4 hr.: Massage should be avoided in cases of DVT as it can dislodge the thrombus, leading to a pulmonary embolism or other life-threatening complications.
C. Administer aspirin for pain.: Aspirin is not recommended for clients on anticoagulant therapy, as it can increase the risk of bleeding. Other pain relief options should be considered that do not interact with anticoagulants.
D. Initiate bed rest.: While limited activity is necessary to prevent the risk of embolism, complete bed rest is not typically recommended. Early ambulation (when safe. is often encouraged to prevent complications like venous stasis.
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