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 should wear a mask during transport. In droplet precautions, the primary goal is to prevent the spread of respiratory secretions. The client wearing a mask during transport helps contain droplets and protect others.
B. The nurse should wear a mask during transport: While the nurse can wear a mask when in close contact with the client, it is more effective for the client to wear a mask to contain respiratory droplets.
C. The nurse should wear a gown during transport: Gowns are not required for droplet precautions unless there is a risk of contact with bodily fluids.
D. The client should wear a gown during transport: Gowns are unnecessary for droplet precautions unless the client’s clothing is contaminated.

A. Obtain the client's peak expiratory flow volume. B. Encourage the client to cough. C. Place the client in a semi-Fowler's position. D. Encourage the client to use a straw to sip cool liquids.

Correct Answer is C

Explanation

A. Obtain the client's peak expiratory flow volume: This is unnecessary in this context and not a routine assessment post-tonsillectomy.
B. Encourage the client to cough: Coughing can irritate the surgical site and increase the risk of bleeding.
C. Place the client in a semi-Fowler's position. Semi-Fowler's position promotes optimal airway clearance and reduces the risk of aspiration or airway obstruction.
D. Encourage the client to use a straw to sip cool liquids: Straws are contraindicated because the suction action can disrupt the surgical site and cause bleeding.

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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 C

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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.