A nurse is caring for a client.

Click on the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Nurses' Notes

1500:

Client is alert and oriented to person, place, and time. Client is 4 hr postoperative following abdominal surgery. Surgical site has a small amount of serosanguineous drainage on dressing. Dressing is intact. Client reports pain as 5 on a scale of 0 to 10. Lung sounds are diminished in posterior lobes. Bowel sounds are hypoactive in all 4 quadrants. Last bowel movement was this morning.

1730:

Client is restless and short of breath. Reports pain as 8 on a scale of 0 to 10. Pain medication administered.

Vital Signs

1730:

• Temperature 37.2° C (98.9° F)
• Blood pressure 168/84 mm Hg
• Heart rate 116/min
• Respiratory rate 24/min
• Oxygen saturation 93% on room air

Choice A reason:
A blood glucose level of 110 mg/dl: A slightly elevated blood glucose level could be expected in response to enteral feeding.
Choice B reason:
Diarrhea one time in a 24-hour period is incorrect. Diarrhea can occur as a side effect of enteral feeding due to changes in the digestive process.
Choice C reason:
An unexpected finding when a client is receiving continuous enteral feeding via an NG tube is a rapid and significant weight gain of 0.91 kg (2 lb) in just 2 days. This could indicate fluid overload, which might be caused by excessive fluid intake or inadequate fluid removal by the body. Rapid weight gain should be assessed and reported as it could be a sign of underlying issues that need to be addressed.
Choice D reason:
A gastric residual of 300 mL at the end of the shift is incorrect. Gastric residuals can fluctuate during continuous enteral feeding, and a residual of 300 mL may not necessarily be unexpected depending on the client's overall condition and the healthcare provider's guidelines.

Choice A reason:
Powdered gloves are more likely to release latex particles into the air, which can increase the risk of exposure for a client with a latex allergy. Therefore, using non-powdered gloves is recommended.
Choice B reason:
Scheduling the client as the first surgical procedure of the day is the appropriate action because it can help minimize the risk of latex exposure. This is because latex particles released into the air during previous surgeries can settle in the surgical environment, increasing the risk for individuals with latex allergies. By scheduling the client's surgery as the first procedure, the likelihood of exposure to residual latex particles is reduced.
Choice C reason:
Removing the stopcocks from IV tubing does not directly address the risk of latex exposure in a surgical setting.
Choice D reason:
Cleansing stoppers with povidone-iodine is a good practice for infection control but does not specifically address the risk of latex exposure for a client with a latex allergy during surgery.