The nurse is assisting with the care of a client.

Exhibits

The nurse is collecting data on the client. Which of the following findings require follow-up?

Select all that apply.

Blood pressure

BUN level

Potassium level Abdominal findings

WBC count

Breath sounds

Answer and Explanation

Correct Answer : A,B,C,D

A. Blood pressure: The client’s blood pressure (92/60 mm Hg) is low, which is concerning, especially with tachycardia (HR 106). This may indicate hypovolemia or shock, which requires immediate attention.
B. BUN level: The BUN level (25 mg/dL) is elevated above the normal range, which could indicate dehydration or kidney dysfunction, often seen in conditions like gastrointestinal obstruction or sepsis.
C. Potassium level: The potassium level (3.3 mEq/L) is below the normal range (3.5 to 5 mEq/L), which can contribute to arrhythmias and muscle weakness, often a result of vomiting, diarrhea, or dehydration.
D. Abdominal findings: The high-pitched bowel sounds and tenderness are consistent with an intestinal obstruction, and further assessment and intervention are necessary to manage the condition effectively.
E. WBC count: The WBC count (9,000/mm³) is within the normal range, suggesting no active infection or inflammation at the moment.
F. Breath sounds: Bilateral breath sounds are clear, which suggests no current respiratory issues or pneumonia, allowing the focus to remain on gastrointestinal findings.

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Correct Answer is A

Explanation

A. The client has an inspiratory stridor. Inspiratory stridor indicates airway obstruction or laryngeal edema, a potentially life-threatening complication following a bronchoscopy that requires immediate intervention.
B. The client reports a sore throat: A sore throat is common after bronchoscopy due to irritation from the scope. This does not require reporting.
C. The client’s sputum has streaks of blood: Small amounts of blood in sputum are expected due to minor mucosal trauma.
D. The client’s temperature is 38.6°C (101.4°F): Mild fever can occur post-procedure due to inflammation but should only be reported if it persists or other infection signs develop.

A. Trendelenburg with legs extended B. Supine with knees flexed C. Semi-Fowler's with legs extended D. Left-lateral with knees flexed

Correct Answer is B

Explanation

A. "Trendelenburg with legs extended.": Trendelenburg increases pressure on the abdomen, worsening evisceration.
B. "Supine with knees flexed.": This position reduces abdominal tension, minimizing further protrusion of the contents and providing comfort until surgical intervention.
C. "Semi-Fowler's with legs extended.": This position does not adequately reduce abdominal tension.
D. "Left-lateral with knees flexed.": Lateral positions are not suitable because they do not address abdominal tension or allow easy surgical access.

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The nurse is assisting with the care of a client. Exhibits The nurse is collecting data on the client. Which of the following findings require follow-up? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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The nurse is assisting with the care of a client.

Exhibits

The nurse is collecting data on the client. Which of the following findings require follow-up?

Select all that apply.