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Which four patient assessment findings require follow-up by the nurse? Select all four that apply.

The patient is alert and oriented x4.

The patient reports nausea.

The abdomen is tender to palpation.

The patient is 60 years old.

The patient has dark amber urine.

The patient's oral temperature is 102.4°F.

The patient is voiding without difficulty.

Answer and Explanation

Correct Answer : B,C,E,F

Choice A reason: The patient is alert and oriented x4. This indicates that the patient is fully aware of their surroundings and does not require follow-up for this finding.
Choice B reason: The patient reports nausea. Nausea can be a symptom of many underlying conditions, including gastrointestinal issues or medication side effects, and requires follow-up to determine the cause and provide appropriate treatment.
Choice C reason: The abdomen is tender to palpation. Abdominal tenderness can indicate inflammation, infection, or other abdominal pathology, which requires follow-up to identify the underlying cause and provide appropriate management.
Choice D reason: The patient is 60 years old. This is a demographic detail and does not indicate a medical condition requiring follow-up.
Choice E reason: The patient has dark amber urine. Dark amber urine can be an indication of dehydration or other underlying conditions that require follow-up to identify and address the cause.
Choice F reason: The patient's oral temperature is 102.4°F. A fever indicates the presence of an infection or other health issue that needs to be investigated and managed.
Choice G reason: The patient is voiding without difficulty. This indicates that there are no issues with urinary function, so no follow-up is required for this finding.

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

Explanation

Choice A reason: Applying a clean, dry dressing over the VTE/DVT site is not necessary. VTE/DVT usually involves deep veins where there are no visible wounds requiring dressings. This instruction is irrelevant to the management and discharge instructions for a patient with DVT on anticoagulant therapy.
Choice B reason: Monitoring activated partial thromboplastin time (aPTT) results is relevant for heparin therapy, not for warfarin. Warfarin therapy is monitored using the international normalized ratio (INR). Therefore, this instruction is not appropriate for a patient being discharged on warfarin.
Choice C reason: Administering the warfarin dose at the same time each day is crucial for maintaining consistent blood levels of the medication, ensuring its effectiveness. It helps to maintain steady anticoagulation and reduces the risk of complications associated with fluctuating blood levels of warfarin.
Choice D reason: Instructing the patient to take aspirin or NSAIDs as needed for pain is inappropriate because these medications can increase the risk of bleeding when taken with warfarin. Patients on warfarin should avoid these medications and use alternatives like acetaminophen (Tylenol) for pain relief.
Choice E reason: Advising the patient to use electric razors, not straight razors, when shaving is important to prevent cuts and bleeding. Warfarin increases the risk of bleeding, and using an electric razor minimizes the chance of nicks and cuts that could lead to significant bleeding.
Choice F reason: Monitoring the level of anticoagulation with warfarin using INR results is essential. Regular INR monitoring ensures that the patient maintains a therapeutic level of anticoagulation and helps prevent both clotting and bleeding complications. Adjustments to the warfarin dose are made based on INR results.

A. "I need to shop for foods low in sodium and avoid adding salt to food." B. "I need to limit my fluid intake." C. "I should eat foods high in potassium because diuretics cause potassium loss." D. "I should weigh myself daily and report sudden weight loss or gain."

Correct Answer is ["B","C"]

Explanation

Choice A reason: "I need to shop for foods low in sodium and avoid adding salt to food." This statement is correct and indicates appropriate understanding. Patients with SIADH need to manage their sodium intake carefully to avoid exacerbating hyponatremia.
Choice B reason: "I need to limit my fluid intake." This statement indicates a misunderstanding. Patients with SIADH should actually increase their fluid intake to help dilute the excess antidiuretic hormone and reduce hyponatremia. Limiting fluid intake can worsen the condition.
Choice C reason: "I should eat foods high in potassium because diuretics cause potassium loss." This statement is incorrect in the context of SIADH. While potassium intake is important for patients on diuretics, it is not directly related to SIADH management. The focus should be on managing fluid and sodium levels.
Choice D reason: "I should weigh myself daily and report sudden weight loss or gain." This statement is correct and indicates appropriate understanding. Regular weight monitoring is important for patients with SIADH to detect fluid imbalances early.

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Which four patient assessment findings require follow-up by the nurse? Select all four that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

Which patient statement indicates to the nurse that further instruction is needed about chronic syndrome of inappropriate antidiuretic hormone (SIADH)?

Correct Answer is ["B","C"]

Explanation

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