A male client with a chronic medical condition tells the practical nurse (PN) that he wants no heroics to prolong his life if anything should happen to him. Which action should the PN take?

Heart rate of 90 beats per minute with premature ventricular contractions (PVCs) noted on telemetry: This finding indicates an abnormality in the heart's electrical conduction system. PVCs are extra, abnormal heartbeats that originate in the ventricles. They can sometimes be benign, but they can also be associated with underlying heart conditions or electrolyte imbalances. Since the client is experiencing dizziness and tingling, which could be related to cardiac function, it is important to report this finding to the healthcare provider for further evaluation and appropriate management.

Incorrect:

A. Regular heart rate of 100 beats per minute on telemetry: This finding describes a heart rate within the normal range (60-100 beats per minute for adults). It does not indicate any immediate concerns or abnormalities that would require reporting to the healthcare provider in this context.
B. Hypoactive bowel sounds on assessment: Following a small bowel resection, it is common for bowel sounds to be temporarily reduced or absent due to the surgical manipulation and the bowel's response to anesthesia. Hypoactive bowel sounds alone do not directly relate to the client's reported symptoms of dizziness and tingling in digits, nor do they suggest an immediate need for reporting to the healthcare provider.
D. Hyperactive bowel sounds on assessment: Hyperactive bowel sounds, characterized by increased loudness and frequency, can occur due to conditions such as gastroenteritis or bowel obstruction. However, in the context of a client who has undergone a small bowel resection and is on NPO status, hyperactive bowel sounds would not be expected and may indicate a potential complication. While it is important to monitor and document this finding, it is not directly related to the client's reported symptoms and does not require immediate reporting to the healthcare provider in this scenario.

The practical nurse (PN) should include the following actions when assessing a client for signs and symptoms of fluid volume excess:

• Palpate the rate and volume of the pulse: Fluid volume excess can lead to an increased pulse rate and bounding pulse due to the increased blood volume.
• Measure body weight at the same time daily: Monitoring daily weights can help identify fluid retention or weight gain, which can be indicative of fluid volume excess.
• Observe the color and amount of urine: Changes in urine color and output can provide information about kidney function and fluid balance. In fluid volume excess, urine output may be increased and urine may appear pale or diluted.

The following options are incorrect:

• Check fingernails for the presence of clubbing: Clubbing of the fingernails is not directly related to fluid volume excess. It is a finding commonly associated with chronic respiratory conditions and certain cardiac disorders.
• Compare muscle strength of both arms: Assessing muscle strength is not directly related to fluid volume excess. It is more relevant when evaluating neurological or musculoskeletal conditions.