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
The client has an implanted defibrillator is the correct answer. Magnet therapy involves the use of magnets to alleviate pain and promote healing. However, it is contraindicated for individuals with implanted electronic devices, such as pacemakers or defibrillators, as the magnetic field could potentially interfere with the functioning of these devices. The safety of using magnet therapy with implanted devices has not been established, and caution is advised.
Choice B reason:
Allergic to penicillin is incorrect. Allergies to penicillin or other substances are not related to the use of magnet therapy.
Choice C reason:
The history of alcohol use disorder is incorrect. A history of alcohol use disorder does not directly contraindicate the use of magnet therapy.
Choice D reason:
The prescription for metoprolol is incorrect. Metoprolol is a common medication used to treat various conditions, including hypertension and certain heart conditions. It is not a contraindication for magnet therapy.