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 C

Explanation

A. The top image shows a client's neck with a visible swelling in the area of the thyroid gland, which is consistent with goiter, another common finding in Graves' disease, but is not exophthalmos.
B. The middle image shows a hand, which is not relevant to the ocular manifestations of this condition.
C. The bottom image shows the client's eyes with a noticeable bulging appearance and retracted eyelids, making the whites of the eyes visible above and below the iris. This is the characteristic clinical appearance of exophthalmos

A. Oropharyngeal airway B. Yankauer catheter C. Sterile gloves D. Water-soluble lubricant

Correct Answer is B

Explanation

A. Oropharyngeal airway: An oropharyngeal airway is used to maintain an open airway in clients who cannot protect their own airway, not for performing suctioning. It does not assist with clearing secretions and would not replace the function of suction equipment in the home setting.

B. Yankauer catheter: A Yankauer catheter is specifically designed for oropharyngeal suctioning because its rigid tip safely removes oral secretions without damaging tissue. It allows the client or caregiver to maintain airway clearance effectively at home. This is the appropriate device needed for routine oral suctioning.

C. Sterile gloves: While gloves are necessary for infection control, suctioning in the home typically requires clean rather than sterile technique. The environment does not require sterile supplies, and the priority is having the correct suction device available.

D. Water-soluble lubricant: Lubricant is used for procedures such as nasopharyngeal or endotracheal suctioning to reduce tissue irritation. Oropharyngeal suctioning with a Yankauer does not require lubrication because the catheter is inserted only into the mouth. Therefore, lubricant is unnecessary for this procedure.

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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 collecting data from a client who has Graves' disease. Which of the following images should the nurse identify as an indication that the client is experiencing exophthalmos?

Correct Answer is C

Explanation

A nurse is assisting with discharge teaching for a client who requires oropharyngeal suctioning at home. The nurse should ensure that which of the following equipment is available for use at home?

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.