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

WBC count

Abdominal findings

BUN level

Potassium level

Blood pressure

Breath sounds

Answer and Explanation

Correct Answer : B,C,D,E

A. WBC count: The WBC count is within the normal range and does not indicate infection or inflammatory worsening at this time. It does not require urgent follow-up compared with other more concerning findings in this presentation.

B. Abdominal findings: High-pitched bowel sounds, pain, vomiting, and tenderness correlate with small-bowel obstruction and signal worsening motility. These findings raise concern for progression toward ischemia or perforation, so they require prompt follow-up.

C. BUN level: The elevated BUN suggests dehydration from vomiting and third-spacing associated with obstruction. This may lead to worsening renal perfusion if not corrected, indicating a need for timely follow-up and fluid management.

D. Potassium level: The potassium level is low and may worsen due to continued fluid losses, placing the client at risk for arrhythmias. Correction and monitoring are important, especially in the context of dehydration and tachycardia.

E. Blood pressure: The low blood pressure and elevated pulse indicate possible hypovolemia from fluid shifts and decreased intake. This hemodynamic change requires intervention to prevent further decline and maintain organ perfusion.

F. Breath sounds: Breath sounds are clear bilaterally and show no signs of respiratory involvement. They are not concerning in relation to the client’s current abdominal pathology and do not need immediate follow-up.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

• Determine if the nasogastric tube is in the correct position: The client reports nausea and the NG tube is not draining, which may indicate malposition or blockage. Verifying tube placement is the priority because improper placement can cause ineffective decompression, aspiration, or injury to the gastrointestinal tract.

• Request a prescription for an antiemetic: Administering an antiemetic may mask symptoms without addressing the underlying issue of a nonfunctional NG tube. Treating nausea alone does not resolve the obstruction or improve decompression.

• Increase the nasogastric tube suction: Increasing suction before confirming proper tube placement may cause injury or irritation to the gastric mucosa and does not guarantee effective drainage if the tube is malpositioned or blocked.

• Repositioning the nasogastric tube: If the tube is correctly placed but not draining, repositioning can help restore patency and proper gastric decompression. This ensures relief from nausea, prevents further distention, and maintains electrolyte balance.

• Placing the client in semi-Fowler's position: While semi-Fowler’s may help reduce risk of aspiration and improve comfort, it does not address the primary problem of a nonfunctional NG tube and should follow verification and repositioning.

• Providing the client with mouth care: Mouth care is important for comfort and infection prevention, but it does not address the urgent problem of nausea and impaired gastric decompression.

A. "I am only contagious while the lesions are present." B. "The lesions may reoccur in times of stress." C. "The virus cannot spread to areas other than the genital area." D. "I can have unprotected sex as long as I am taking acyclovir."

Correct Answer is B

Explanation

A. "I am only contagious while the lesions are present.": HSV-2 can be transmitted even when no lesions are visible due to asymptomatic viral shedding. Relying solely on the presence of lesions for precautions increases the risk of spreading the virus.

B. "The lesions may reoccur in times of stress.": HSV-2 can reactivate during periods of stress, illness, or immunosuppression, leading to recurrent genital lesions. Understanding this helps the client anticipate and manage flare-ups appropriately.

C. "The virus cannot spread to areas other than the genital area.": HSV-2 can infect other areas through direct contact, such as oral-genital transmission or autoinoculation. Clients should be aware of the potential for spreading the virus beyond the genital region.

D. "I can have unprotected sex as long as I am taking acyclovir.": Antiviral therapy reduces viral shedding but does not eliminate the risk of transmission. Safe sex practices, including condom use, remain necessary to prevent spreading HSV-2 to partners.

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

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Naxlex Comprehensive Predictor Exams

The nurse is assisting with the care of a client. Complete the following sentence by using the lists of options. The nurse is assisting with the plan of care for the client. The nurse should first plan to dropdown followed by dropdown.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

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Correct Answer is B

Explanation

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