A nurse is assisting with the care of a client.
Select the 3 findings that require immediate follow up
Heart rate
Pedal pulses
Breath sounds
Abdominal dressing
Respiratory rate
Oxygen saturation
Correct Answer : A,D,E
A. Heart rate: The increase from 88/min to 110/min indicates tachycardia, which can be an early sign of hypovolemia, infection, or sepsis. When combined with hypotension and fever, this finding suggests possible postoperative complications requiring urgent evaluation.
B. Pedal pulses: Bilateral pedal pulses remain 2+, indicating adequate peripheral perfusion at this time. This finding is stable and does not suggest acute circulatory compromise requiring immediate follow-up.
C. Breath sounds: Breath sounds are clear and unchanged from admission, suggesting no current pulmonary complication such as atelectasis or pneumonia. This finding does not indicate an urgent problem.
D. Abdominal dressing: A sudden increase to a large amount of serosanguinous drainage after the client felt something “pop” raises concern for wound dehiscence or possible evisceration. This is a surgical emergency requiring immediate assessment and intervention.
E. Respiratory rate: The respiratory rate has increased from 18/min to 24/min, indicating tachypnea. This may reflect pain, infection, or developing sepsis and warrants prompt follow-up in the postoperative client.
F. Oxygen saturation: Oxygen saturation remains within an acceptable range at 95% on room air. Although it should continue to be monitored, it does not currently indicate acute respiratory compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. “I insert needles into meridian lines of my child's body to help with pain relief.”: Inserting needles along meridian lines describes acupuncture, a traditional practice aimed at balancing energy flow. Acupuncture does not involve suction or heated containers placed on the skin.
B. "I rub the edge of a coin lengthwise on my child's back when he is sick.": Rubbing a coin on the back refers to coining, also known as gua sha, which is used to release illness or bad energy. Coining produces linear marks rather than circular suction marks.
C. “I sometimes place a bottle containing steam against my child's skin.": Placing a heated bottle or cup against the skin creates suction as the air cools, which is characteristic of cupping therapy. Cupping commonly leaves circular marks due to localized pressure and increased blood flow.
D. "I apply petroleum jelly with garlic along my child's wrist to treat infectious disease.": Applying garlic with petroleum jelly reflects a topical folk remedy. This specific practice is not formally categorized as cupping or acupuncture
Correct Answer is B
Explanation
A. “I will need to remain upright for 1 hour after taking the medication.”: Remaining upright after taking medication is typically recommended for medications that may cause esophageal irritation, such as certain tablets or NSAIDs, but pantoprazole does not require this. Upright positioning is not necessary specifically for proton pump inhibitors.
B. “I have to take this medication on an empty stomach.”: Pantoprazole, a proton pump inhibitor, is best absorbed when taken 30–60 minutes before a meal. Taking it on an empty stomach enhances its effectiveness in reducing gastric acid secretion and managing GERD symptoms.
C. “I can take antacids at the same time as this medication.”: Antacids can be taken with pantoprazole, but it is generally recommended to separate the timing by at least 30 minutes to avoid affecting the absorption and effectiveness of the proton pump inhibitor.
D. “I should expect to have diarrhea while taking this medication.”: While diarrhea can be a potential side effect of pantoprazole, it is not expected for every client. Most clients tolerate the medication well without gastrointestinal upset.
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