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A nurse is assisting with the care of a client

Exhibits
Select the 3 findings that require immediate follow-up.

Pedal pulses

Heart rate

Oxygen saturation

Blood pressure

Abdominal dressing

Breath sounds

Answer and Explanation

Correct Answer : B,D,E

Rationale:

• Heart rate of 110/min indicates tachycardia, which can be an early sign of hypovolemia, sepsis, or pain and should be followed up due to the recent report of a "popping" sound and increased drainage.
• Abdominal dressing now has a large amount of serosanguinous drainage, suggesting possible wound dehiscence or evisceration, which is a surgical emergency requiring prompt evaluation.
• Blood pressure of 98/50 mm Hg indicates hypotension, which, along with tachycardia and fever, suggests potential sepsis or internal fluid loss and needs immediate intervention.

• Pedal pulses are 2+, which is within normal limits and unchanged from Day 1, indicating adequate peripheral perfusion at present.
• Oxygen saturation at 95% on room air is within normal limits and not significantly changed from previous levels, requiring no urgent action.
• Breath sounds are still clear and present bilaterally, indicating no respiratory compromise or pulmonary complication at this time.

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Correct Answer is B

Explanation

Rationale:

A. "I should gain half of a pound per week to meet my treatment goal": Weight gain goals for clients with anorexia nervosa are typically more aggressive, often around 1 to 3 pounds per week, to restore healthy weight timely and prevent complications of prolonged malnutrition.

B. "The staff will watch me closely for 1 hour after each meal": Monitoring clients after meals is essential to prevent purging behaviors, such as vomiting or excessive exercise. The one-hour observation period helps ensure safety and supports recovery.

C. "The treatment goal is to be within 60 percent of my ideal body weight.": Treatment aims to restore clients to at least 85 to 90 percent of their ideal body weight to improve physical and psychological health; 60 percent is dangerously low and not an appropriate goal.

D. "The staff will weigh me every night before I go to bed.": Weighing is typically done once in the morning before breakfast and after voiding, to ensure consistency and accuracy. Nighttime weighing is not standard practice and may contribute to anxiety.

A. "You should eat three large meals and two snacks per day." B. "You should elevate the head of the bed while sleeping C. "You should only drink 2 cups of coffee per day." D. "You should lay down for 1 hour following a meal."

Correct Answer is B

Explanation

Rationale:

A. "You should eat three large meals and two snacks per day." Eating large meals increases gastric pressure and can worsen reflux symptoms by promoting the backflow of stomach acid into the esophagus. Clients with GERD are advised to consume smaller, more frequent meals to reduce gastric distention.

B. "You should elevate the head of the bed while sleeping." Elevating the head of the bed helps prevent nighttime reflux by using gravity to reduce the likelihood of stomach acid flowing back into the esophagus. This is a key non-pharmacologic strategy in managing GERD symptoms during sleep.

C. "You should only drink 2 cups of coffee per day." Coffee, regardless of the quantity, can relax the lower esophageal sphincter and stimulate acid production. Rather than limiting intake to two cups, clients with GERD are often advised to avoid coffee altogether or monitor symptoms closely.

D. "You should lay down for 1 hour following a meal." Lying down after eating increases the risk of acid reflux due to the horizontal position reducing the effect of gravity. Clients should remain upright for at least 2 to 3 hours after meals to minimize reflux episodes.

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A nurse is assisting with the care of a client Exhibits Select the 3 findings that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a mental health unit is reinforcing teaching with a client who has anorexia nervosa. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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A nurse is assisting with the care of a client

Exhibits
Select the 3 findings that require immediate follow-up.