A home health nurse is assessing a client receiving TPN infusion for malabsorption after extensive bowel surgery. What finding is most important for the nurse to report to the health care provider?
Low-grade fever
Fatigue
Anorexia
Hypoactive bowel sounds
The Correct Answer is A
A. Low-grade fever: A low-grade fever could indicate an infection or other complications related to TPN or bowel surgery, and it is crucial to report this to the healthcare provider.
B. Fatigue: While fatigue is a common symptom, it is less urgent compared to a potential infection.
C. Anorexia: Anorexia is a concern but is not as immediate as a fever.
D. Hypoactive bowel sounds: This is expected after extensive bowel surgery and may not be as urgent as signs of infection.
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Related Questions
Correct Answer is C
Explanation
A. Abdomen soft, surgical dressing has scant amount of old drainage: A soft abdomen and minimal old drainage from the surgical dressing are expected findings postoperatively. They do not indicate an immediate concern that requires prompt action.
B. Client ambulating with minimal assistance, complaints of occasional nausea: Ambulation and occasional nausea are common and generally expected postoperatively. These findings do not require urgent collaboration with the healthcare provider.
C. Crackles bilaterally in bases of lungs, has incisional pain: Crackles in the lungs can indicate fluid accumulation or atelectasis, which may lead to pneumonia or other respiratory complications. This finding, especially combined with recent surgery, requires prompt evaluation and intervention.
D. Temperature 99.4°F (37.4°C), pulse 100 bpm, bowel sounds present: A slightly elevated temperature and increased pulse are common after surgery. The presence of bowel sounds is a positive sign indicating the return of gastrointestinal function. These findings are not immediately concerning.
Correct Answer is D
Explanation
A. Increased cardiac output: In older adults, cardiac output typically decreases, not increases, and this has a minor impact on nutritional status.
B. An increase in GI motility and absorption: GI motility and absorption generally decrease with age, not increase, which can affect nutritional status.
C. Constant snacking between meals that results in obesity: Obesity is less common in healthy older adults compared to issues related to malnutrition or economic factors.
D. Living alone on a fixed income: This can significantly impact nutritional status due to potential financial constraints affecting food availability and quality.
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