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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Improved respiratory function: Pancrelipase is a digestive enzyme replacement and does not directly improve lung function. Respiratory management in cystic fibrosis requires separate interventions such as airway clearance and inhaled medications.

B. Improved absorption of vitamins B and C: Pancrelipase primarily aids in the digestion of fats, proteins, and carbohydrates. While it improves absorption of fat-soluble vitamins (A, D, E, K), it does not specifically enhance absorption of water-soluble vitamins like B and C.

C. Decreased sodium excretion: Pancrelipase does not influence electrolyte excretion, including sodium. Electrolyte management in cystic fibrosis requires separate monitoring and supplementation as needed.

D. Reduced fat in the stools: The therapeutic effect of pancrelipase is to aid digestion of fats, reducing steatorrhea (fatty stools). Successful treatment improves nutrient absorption and decreases gastrointestinal symptoms related to fat malabsorption.

A. 32 lb B. 8 lb C. 24 lb D. 16lb

Correct Answer is D

Explanation

A. 32 lb: A weight gain of 32 lb exceeds the recommended range for a client with a prepregnancy BMI ≥30 (obese). Excessive weight gain increases the risk of gestational diabetes, hypertension, and complications during delivery. Staying within guideline ranges supports maternal and fetal health.

B. 8 lb: A gain of 8 lb is below the recommended range and may indicate inadequate nutrition, which can compromise fetal growth and development. Clients with obesity are advised to gain more than this to support a healthy pregnancy while avoiding excessive weight.

C. 24 lb: A gain of 24 lb slightly exceeds the recommended range for obese clients. While less risky than very high gains, it may still increase the likelihood of postpartum weight retention and obstetric complications.

D. 16 lb: For a prepregnancy BMI ≥30, the recommended total weight gain is 11–20 lb. A gain of 16 lb falls within this guideline, balancing the needs of fetal growth while minimizing maternal and fetal complications. This makes it the most appropriate target for dietary teaching.

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

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Naxlex Comprehensive Predictor Exams

A nurse is administering pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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A nurse is assisting with the care of a client.

Select the 3 findings that require immediate follow up