The nurse calls the healthcare provider because a client diagnosed with an abdominal aortic aneurysm (AAA) is reporting of low back pain. Which additional information about the client would be important for the nurse to tell the healthcare provider?

White blood cell count and pulse rate.

Hematocrit and blood pressure.

Calcium level and skin condition.

Serum amylase and level of consciousness.

Answer and Explanation

The Correct Answer is B

Choice A reason: White blood cell count and pulse rate are not the most important information about the client that the nurse should tell the healthcare provider, because they are not directly related to the AAA or the low back pain. White blood cell count is a measure of the immune system activity, and it may be elevated in cases of infection or inflammation, but it is not specific to AAA. Pulse rate is a measure of the heart rate, and it may be increased in cases of anxiety, pain, or shock, but it is not indicative of AAA.

Choice B reason: Hematocrit and blood pressure are the most important information about the client that the nurse should tell the healthcare provider, because they are directly related to the AAA and the low back pain. Hematocrit is a measure of the percentage of red blood cells in the blood, and it may be decreased in cases of bleeding or anemia, which can occur if the AAA ruptures or leaks. Blood pressure is a measure of the force of the blood against the walls of the arteries, and it may be increased in cases of hypertension or stress, which can worsen the AAA or cause it to rupture. The nurse should monitor the client's hematocrit and blood pressure closely and report any changes to the healthcare provider.

Choice C reason: Calcium level and skin condition are not the most important information about the client that the nurse should tell the healthcare provider, because they are not directly related to the AAA or the low back pain. Calcium level is a measure of the amount of calcium in the blood, and it may be abnormal in cases of bone disorders, kidney disorders, or parathyroid disorders, but it is not relevant to AAA. Skin condition is a general term that can describe the appearance, texture, color, or temperature of the skin, and it may be altered in cases of infection, allergy, or injury, but it is not specific to AAA.

Choice D reason: Serum amylase and level of consciousness are not the most important information about the client that the nurse should tell the healthcare provider, because they are not directly related to the AAA or the low back pain. Serum amylase is a measure of the amount of amylase, an enzyme that digests starch, in the blood, and it may be elevated in cases of pancreatitis, gallstones, or intestinal obstruction, but it is not associated with AAA. Level of consciousness is a measure of the client's mental status, alertness, and responsiveness, and it may be impaired in cases of brain injury, stroke, or coma, but it is not indicative of AAA.

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Correct Answer is B

Explanation

Choice A reason: Overall fluid intake should not be limited, but rather increased, for a client with urinary tract calculi. Increasing fluid intake can help flush out the stones and prevent new ones from forming.

Choice B reason: Tea and hot chocolate should be limited, because they contain oxalates, which can increase the risk of calcium oxalate stones, the most common type of urinary tract calculi. Other foods high in oxalates include spinach, rhubarb, nuts, and chocolate.

Choice C reason: Low-sodium soups are not a problem for a client with urinary tract calculi, unless they have other conditions that require sodium restriction, such as hypertension or heart failure. Sodium intake does not directly affect the formation of stones, but it can increase calcium excretion in the urine, which can contribute to calcium oxalate stones.

Choice D reason: Citrus fruit juices are beneficial for a client with urinary tract calculi, because they contain citrate, which can prevent the crystallization of calcium and oxalate in the urine. Citrate can also help dissolve existing stones and prevent new ones from forming.

A. Explain specific reason for urgent notification. B. Obtain a PRN prescription for acetaminophen for fever over 101° F (38.3° C). C. Preface the report by stating the client’s name and admitting diagnosis. D. Communicate the pre-transfusion temperatures.

Correct Answer is C

Explanation

Choice A reason: Explaining the specific reason for urgent notification is important, but it is not the first information that the nurse should provide. The nurse should first identify the client and the situation, then provide the background, assessment, and recommendation.

Choice B reason: Obtaining a PRN prescription for acetaminophen for fever over 101° F (38.3° C) is a possible recommendation that the nurse can make, but it is not the first information that the nurse should provide. The nurse should first identify the client and the situation, then provide the background, assessment, and recommendation.

Choice C reason: Prefacing the report by stating the client’s name and admitting diagnosis is the first information that the nurse should provide, according to the SBAR communication process. This helps to establish the identity and context of the client and the situation.

Choice D reason: Communicating the pre-transfusion temperatures is part of the assessment that the nurse should provide, but it is not the first information that the nurse should provide. The nurse should first identify the client and the situation, then provide the background, assessment, and recommendation.

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The nurse calls the healthcare provider because a client diagnosed with an abdominal aortic aneurysm (AAA) is reporting of low back pain. Which additional information about the client would be important for the nurse to tell the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about dietary restrictions. In discussing food intake, the nurse should include which type of fluid limitation?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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