Select the 3 findings on day 3 that require immediate follow-up.
PICC line insertion site
Breath sounds
Temperature
Heart rate
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Oatmeal is generally considered a good food for individuals with GERD as it can help absorb stomach acid.
B. Apples are typically a safe fruit for GERD sufferers.
C. Chocolate can relax the lower esophageal sphincter and may worsen GERD symptoms, so it should be avoided.
D. Nonfat milk is usually tolerated better than full-fat dairy products and may help soothe the stomach.
Correct Answer is ["A","C","D"]
Explanation
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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