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Exhibits

The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up:

Blood glucose level

Bowel sounds

Blood pressure

Pain level

Electrocardiogram findings

Lung sounds

Troponin T level

Answer and Explanation

Correct Answer : C,D,E,G

C. The blood pressure readings show significant variability (164/80 mm Hg at 1000, 176/82 mm Hg at 1015, and 110/62 mm Hg at 1200). These fluctuations, especially the higher readings, indicate potential instability and require close monitoring and possibly intervention.
D. The client's pain level is described as 7/10 initially (1000) and decreases to 5/10 after nitroglycerin (1200). Although the pain has decreased, ongoing assessment is necessary to ensure it does not worsen or change in nature.
E. The 12-lead electrocardiogram (ECG) shows tachycardia with ST segment elevation and T wave changes, which are indicative of myocardial ischemia or infarction. This finding requires immediate attention as it suggests ongoing cardiac damage.
G. The troponin T level is elevated at 0.40 ng/mL (normal is less than 0.1 ng/mL). Troponin elevation indicates myocardial injury or infarction and confirms the seriousness of the cardiac event. This finding requires immediate attention to assess the extent of myocardial damage and guide further treatment.

Incorrect Choices
A. While it is slightly elevated, it is not significantly outside the normal range and does not suggest immediate danger or require urgent intervention in the context of the acute cardiac issue. However, monitoring blood glucose levels is important for overall management, especially in a client with diabetes mellitus.
B. The assessment of bowel sounds being present in all 4 quadrants is a normal finding and indicates normal gastrointestinal function. While bowel sounds are important for assessing gastrointestinal health, they are not immediately pertinent to the acute cardiac issue described in the scenario.
F. The nurse notes that lung sounds are clear to auscultation in all lobes, which is a normal finding. Clear lung sounds suggest normal respiratory function and do not require immediate attention in the context of the acute cardiac event described.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

C. This action demonstrates advocacy by ensuring the client has access to necessary support services that can help them maintain independence and receive adequate care in their home environment.

A Reminding the client about medication adherence is important for the client's health management, but they do not directly advocate for the client's autonomy and support system.

B. While this advice is prudent for reducing infection risk, it may limit the client's social interactions and independence. Advocacy involves balancing health promotion with the client's autonomy and quality of life.

D. Raw vegetables may carry a risk of foodborne infections, which can be more severe for individuals with compromised immune systems, such as those with AIDS.

A. Remain at least 1 foot away from young children during treatment. B. Use cloth handkerchiefs instead of disposable tissues. C. Use absorbent briefs for incontinence as needed. D. Flush the toilet with the lid closed three times after use.

Correct Answer is D

Explanation

D. This practice is recommended as a safety precaution to minimize the risk of radioactive contamination following treatment with radioactive isotopes. It helps to ensure that any residual radioactivity is contained and not inadvertently spread, which is particularly important in shared or public bathrooms.

A The recommended distance is typically at least 1 meter (approximately 3 feet), although specific guidelines may vary depending on the type and dose of radiation used.

B. The use of cloth handkerchiefs versus disposable tissues does not significantly affect radiation safety. The focus should be on minimizing contamination and ensuring proper disposal of any tissues or materials that come into contact with bodily fluids.

C. While managing incontinence appropriately is important for comfort and hygiene, it is not directly related to radiation safety. Clients should use standard incontinence products as needed, ensuring proper disposal and hygiene practices.

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Exhibits The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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Exhibits

The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up: