Select the 3 findings on day 3 that require immediate follow-up.

Exhibits

PICC line insertion site

Breath sounds

Temperature

Heart rate

Answer and Explanation

Correct Answer : A,C,D

A. PICC line insertion site: The client reports pain, redness, and edema at the PICC line insertion site, which are signs of a possible infection. This finding requires immediate follow-up to prevent complications like bloodstream infection or sepsis.

B. Breath sounds: The client’s breath sounds are clear and unchanged from Day 1, so this finding does not require immediate follow-up.

C. Temperature: The client's temperature has risen to 39 °C (102.2 °F) from 37.2 °C (99 °F) on Day 1. Such a significant increase in temperature indicates a possible infection and needs prompt intervention.

D. Heart rate: The client’s heart rate has increased to 108/min from 66/min, suggesting tachycardia. This could be a response to infection, potentially linked to sepsis, and warrants immediate follow-up.

E. Albumin level: The albumin level has increased to within the normal range, which is a positive trend and does not require urgent intervention.

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Correct Answer is D

Explanation

A. Rounded describes a normal abdomen but does not convey the greater extent of fullness seen in this case.

B. Scaphoid describes a concave abdomen, which does not apply to this situation.

C. Flat indicates no significant contour changes, which does not apply here.

D. Protuberant is the correct term, as it describes an abdomen that is significantly distended and is characteristic of conditions like pregnancy, ascites, or obesity.

A. Blood pressure 178/90 mm Hg B. Low body temperature C. Jugular vein distention D. Skin tenting present

Correct Answer is D

Explanation

A. Elevated blood pressure is not an indication of dehydration; dehydration is more likely to cause a drop in blood pressure due to decreased blood volume.

B. Dehydration typically does not cause a low body temperature; instead, it can lead to an elevated temperature as the body conserves water.

C. Jugular vein distention is associated with fluid overload or heart failure, not dehydration.

D. Skin tenting, where the skin remains elevated after being pinched, is a classic sign of dehydration due to reduced skin elasticity.

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Select the 3 findings on day 3 that require immediate follow-up. Exhibits

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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Select the 3 findings on day 3 that require immediate follow-up.

Exhibits