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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["A","C","E"]

Explanation

A. Potassium: Spironolactone is a potassium-sparing diuretic. The client’s potassium level of 5.2 mEq/L is above normal, increasing the risk of hyperkalemia. Administering spironolactone in this context is contraindicated until potassium is corrected.

B. BUN: Although the BUN is elevated, indicating possible dehydration or renal impairment, it is not an absolute contraindication. Careful monitoring and dose adjustment may be necessary, but it does not automatically preclude spironolactone use.

C. Allergy: The client has a sulfonamide allergy. Spironolactone contains a sulfonamide group, which can trigger hypersensitivity reactions. This allergy is a clear contraindication to administering the medication.

D. Respiratory rate: The respiratory rate is within a reasonable range and does not affect the safety or efficacy of spironolactone. It is not a contraindication.

E. Creatinine: The elevated creatinine (1.7 mg/dL) indicates impaired renal function. Spironolactone can worsen hyperkalemia and fluid retention in clients with kidney dysfunction, making significant renal impairment a contraindication for its use.

A. Use the same part of stool for each sample. B. Apply five drops of developer to each smear. C. Ensure the sample contains no urine. D. Wait 10 min before applying the developing solution.

Correct Answer is C

Explanation

A. Use the same part of stool for each sample: Samples should be collected from different areas of the stool because blood may not be uniformly distributed. Using the same area could lead to a false-negative result.

B. Apply five drops of developer to each smear: The correct number of drops is specified in the test kit instructions, and five drops may be excessive or insufficient depending on the manufacturer. Following kit directions ensures accurate results.

C. Ensure the sample contains no urine: Urine can interfere with the chemical reaction in the fecal occult blood test and cause false-positive or false-negative results. Keeping the stool free of urine is essential for accurate testing.

D. Wait 10 min before applying the developing solution: The developer should be applied immediately after the stool sample is prepared according to the kit instructions. Waiting unnecessarily could affect the test’s sensitivity and lead to inaccurate results.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse is caring for a client who has a new prescription for spironolactone. Which of the following client findings should the nurse identify as a contraindication to the administration of spironolactone? Select the 3 findings the nurse should identify as a contraindication.

Correct Answer is ["A","C","E"]

Explanation

A nurse is reinforcing teaching with a client who is to take a fecal occult blood test at home. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who is taking phenytoin and has a seizure disorder. For which of the following adverse effects should the nurse monitor the client?

A nurse is caring for a client who has undergone hemodialysis. Which of the following findings should the nurse report to the provider?

A nurse at an urgent care clinic is contributing to the plan of care for a client following a near drowning while attempting to walk across a frozen pond. Which of the following interventions should the nurse recommend?

A nurse is caring for a client who has a tracheostomy tube. Upon data collection, the nurse observes the client is restless and hears crackles in the lungs. Which of the following interventions should the nurse take?

A nurse at a rehabilitation facility is contributing to the plan of care for a client who has had a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

Which of the following actions should the nurse assist with? (Click on the exhibit tabs for additional information about the client. There are six tabs that contain separate categories of data.)

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