Indicate four assessment findings which require immediate follow-up.
BP 85/55.
Hgb 7 g/dL.
Deformed, edematous right lower leg with massive bleeding.
Temp 96.5.
Correct Answer : A,B,C
Choice A rationale
Blood pressure of 85/55 indicates hypotension, which can compromise perfusion to vital organs such as the brain and kidneys. Immediate assessment is necessary to determine the underlying cause, such as dehydration or internal bleeding.
Choice B rationale
Hemoglobin level of 7 g/dL is critically low, falling below the normal range of 12–16 g/dL for women or 13–18 g/dL for men. This reflects severe anemia, which may require urgent intervention, including blood transfusion or addressing the cause of anemia.
Choice C rationale
Massive bleeding from the right lower leg is an emergency due to the risk of hypovolemic shock and significant blood loss. Stabilization of the bleeding site and monitoring for signs of systemic impact is required immediately.
Choice D rationale
A temperature of 96.5°F (35.8°C) may signal mild hypothermia or a systemic condition. While it requires follow-up, it is not as immediately life-threatening as the other findings and therefore does not warrant immediate prioritization.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Checking blood pressure does not directly address the faint pulses and cool foot. While hypotension could contribute to peripheral perfusion issues, the signs described more likely indicate compartment syndrome, which requires urgent action.
Choice B rationale
Repositioning the leg might provide some comfort but does not alleviate the potential compartment syndrome. Elevation could worsen ischemia by reducing arterial blood flow.
Choice C rationale
Compartment syndrome is a medical emergency caused by increased pressure within a muscle compartment. This pressure compromises circulation and tissue viability. The nurse must notify the health care provider immediately to prevent permanent damage.
Choice D rationale
Assessing the incision for redness delays addressing the critical signs of potential compartment syndrome. Redness indicates infection, but faint pulses and a cool extremity necessitate more urgent evaluation.
Correct Answer is D
Explanation
Choice A rationale
Chewing gum can increase salivary production, and while saliva may neutralize some stomach acid, the act of chewing can stimulate swallowing and possibly exacerbate symptoms by introducing excess air into the stomach. For GERD patients, avoiding gum may help reduce bloating and gas discomfort.
Choice B rationale
Elevating the head of the bed reduces the likelihood of acid reflux during sleep by using gravity to prevent stomach contents from flowing backward into the esophagus. This strategy aligns with GERD management guidelines and reduces nighttime symptoms.
Choice C rationale
Taking antacids between meals and at bedtime helps neutralize stomach acid temporarily, providing short-term relief of GERD symptoms. While effective, long-term use without addressing dietary and lifestyle factors is not ideal for managing GERD.
Choice D rationale
Eating small meals is beneficial for GERD, as it prevents overdistension of the stomach, but having a bedtime snack contradicts GERD management principles. Late-night eating may increase the risk of acid reflux when lying down, thus requiring more teaching.
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