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
a small amount of serosanguineous drainage
Lung sounds are diminished in posterior lobes
pain as 5 on a scale of 0 to 10
Blood pressure 168/84 mm Hg
Respiratory rate 24/min
Oxygen saturation 93% on room air
Bowel sounds are hypoactive in all 4 quadrants
The Correct Answer is ["A","B","C","D"]
a small amount of serosanguineous drainage,
Lung sounds are diminished in posterior lobes,
pain as 8 on a scale of 0 to 10,
Blood pressure 168/84 mm Hg
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Sodium 140 mEq/L is incorrect because it falls within the normal range (135-145 mEq/L).
Choice B reason:
A potassium level of 5.8 mEq/L is appropriate because it is above the normal range (typically around 3.5-5.0 mEq/L). Elevated potassium levels, known as hyperkalaemia, can lead to serious cardiac disturbances, including arrhythmias or even cardiac arrest. It is important to notify the healthcare provider promptly so that appropriate interventions can be initiated to address the high potassium level.
Choice C reason:
Calcium 9.6 mg/dL is incorrect because it is within the normal range (8.5-10.5 mg/dL).
Choice D reason:
Magnesium 1.9 mEq/L is incorrect because it is within the normal range (1.5-2.5 mEq/L).
Correct Answer is B
Explanation
Choice A reason:
Wearing a mask when outside of the room is not a standard practice for all patients undergoing an allogeneic stem cell transplant. The need for mask use may vary based on the patient's specific condition and the facility's infection control protocols.
Choice B reason:
"You will be in a negative-airflow room to keep the air cleaner." This is the appropriate answer. An allogeneic stem cell transplant involves replacing the patient's damaged or diseased bone marrow with healthy donor stem cells. Patients undergoing this type of transplant have compromised immune systems due to the treatment, which increases the risk of infection. Placing the patient in a negative-airflow room helps prevent the spread of airborne infections by ensuring that air flows into the room but does not escape into other areas of the facility
Choice C reason:
Visitors wearing protective gowns is not a standard practice for all patients undergoing an allogeneic stem cell transplant. Visitor guidelines may depend on the patient's immune status and specific infection control measures.
Choice D reason:
Being placed in a semi-private room is not recommended for patients undergoing an allogeneic stem cell transplant. These patients require a controlled environment to reduce the risk of infections, and private rooms with proper infection control measures are generally preferred.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today