In assessing a client at 34 weeks gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28% (0.28 volume fraction), a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up?
Reference Range:
Hematocrit [37% to 47% (0.37 to 0.47 volume fraction)]
Hematocrit of 28% (0.28 volume fraction).
Heart rate of 92 beats per minute.
Systolic murmur.
Elevated thyroid hormone level.
The Correct Answer is A
A) Correct- Hematocrit values below the reference range during pregnancy could indicate anemia, which requires further evaluation and intervention. The other findings can be attributed to normal physiological changes during pregnancy (elevated total T4, heart rate increase) or can be common findings (systolic murmur).
B) Incorrect - A heart rate of 92 beats per minute is within the normal range for pregnancy due to increased blood volume and hormonal changes.
C) Incorrect - A systolic murmur can be a common finding during pregnancy due to increased cardiac output.
D) Incorrect - An elevated total T4 can be a normal finding during pregnancy due to hormonal changes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Shortness of breath on exertion in a client with a history of chronic obstructive pulmonary disease (COPD) and pneumonia indicates increased respiratory distress and compromised lung function. It suggests that the client is experiencing difficulty breathing even with minimal physical exertion. This finding may indicate worsening respiratory status, increased oxygen demand, and inadequate oxygenation. The nurse should take immediate action to address the shortness of breath, which may involve providing supplemental oxygen, initiating or adjusting bronchodilator medications, and monitoring the client's respiratory status closely. Prompt intervention is crucial to ensure adequate oxygenation and prevent respiratory failure.
While the other assessment findings (bilateral diffuse wheezing, temperature of 100.5 °F, and yellow expectorated sputum) are also important and require attention, the shortness of breath on exertion poses the greatest immediate risk and necessitates immediate intervention to address the client's respiratory distress.
Correct Answer is A
Explanation
Following a pneumonectomy, it is important for the client to gradually resume normal activities and engage in social interactions. Encouraging family gatherings can provide emotional support, facilitate social connections, and help reduce feelings of isolation that the client may be experiencing.
While it is generally important for clients who have undergone a pneumonectomy to take precautions to reduce the risk of respiratory infections, such as avoiding crowded places and individuals with respiratory infections, completely avoiding social contact for several weeks is not necessary or realistic in most cases. It is essential to find a balance between protecting the client's health and promoting their emotional well-being and social integration.
Wearing a face mask during family events may not be necessary unless there is a specific concern about respiratory infections. The nurse can educate the client about the importance of good hand hygiene and avoiding close contact with individuals who are actively ill with respiratory infections.
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