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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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Correct Answer is B

Explanation

B. Slowing the infusion rate of 0.9% sodium chloride and contacting the provider are appropriate initial actions to manage the client's dyspnea and hypertension, which are likely due to fluid overload from the IV infusion.

A Corticosteroids are not typically indicated for dyspnea and hypertension related to IV fluid administration with 0.9% sodium chloride.

C Changing the type of IV fluid to lactated Ringer's solution may be considered in some cases to address fluid balance issues. However, this decision should be made in consultation with the healthcare provider based on the client's specific clinical condition and fluid status.

D. Lowering the head of the bed to semi-Fowler's position can help improve respiratory function and reduce dyspnea. However, this action alone does not address the underlying cause of the client's symptoms.

A. Check pressure points every 12 hr. B. Provide the client with a trapeze bar. C. Remove the weights before changing the client's bedlinens. D. Instruct the client to use their elbows to reposition.

Correct Answer is B

Explanation

B. Providing the client with a trapeze bar allows them to move and reposition in bed independently without compromising the traction on the affected leg.

A Checking pressure points every 2 hours is generally recommended for clients at risk of developing pressure ulcers, but it's not specific to skeletal traction care.

C. Removing the weights prematurely can lead to loss of traction and compromise the therapeutic benefit of the traction.

D. When a client has skeletal traction, they should avoid using the affected limb for any weight-bearing activities or for repositioning

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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

A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg, a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who has skeletal traction applied to the left leg. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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Exhibits

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