A nurse is caring for a client who had an open cholecystectomy 24 hours ago.

The client’s vital signs have been stable over the last 24 hours, with the most recent temperature

98.6° F(37° C), blood pressure (BP) 118/76 mm Hg, respiratory rate (RR) 16/min, and pulse 78/min, but are now changing.

Which set of vital signs indicates that the nurse should contact the health care provider?

temperature 97.5° F(36.4° C), BP 98/64 mm Hg, pulse 90/min, RR 18/min.

temperature 99.5° F (37.5° C), BP 126/80 mm Hg, pulse 68/min, RR 16/min.

temperature 100.7° F (38.2° C), BP 118/68 mm Hg, pulse 84/min, RR 20/min.

temperature 101.8° F(38.8° C), BP 100/60 mm Hg, pulse 98/min, RR 28/min.

Answer and Explanation

The Correct Answer is D

temperature 101.8° F(38.8° C), BP 100/60 mm Hg, pulse 98/min, RR 28/min. This set of vital signs indicates that the client may have an infection or sepsis, which are potential complications of an open cholecystectomy. The client has a fever, tachycardia, tachypnea, and hypotension, which are signs of systemic inflammatory response syndrome (SIRS).

Choice A is wrong because it shows mild hypothermia, hypotension, and tachycardia, which could be due to dehydration or blood loss, but not necessarily infection.

Choice B is wrong because it shows a slight fever, normal blood pressure, and bradycardia, which could be due to pain or medication, but not infection.

Choice C is wrong because it shows a low-grade fever, normal blood pressure and pulse, and mild tachypnea, which could be due to inflammation or dehydration, but not infection.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Inspection, palpation, percussion, and auscultation are the four techniques used to perform a physical assessment.

Inspection involves observing the patient’s appearance, posture, movement, and behavior. Palpation involves feeling the patient’s skin, organs and pulses with the hands.

Percussion involves tapping the patient’s body with the fingers or a small hammer to elicit sounds or vibrations.

Auscultation involves listening to the patient’s heart, lungs, and bowel sounds with a stethoscope.

Choice A is wrong because relationship and evaluation are not techniques of physical assessment.

Relationship refers to the rapport and trust established between the nurse and the patient.

Evaluation refers to the process of comparing the expected outcomes with the actual outcomes of the nursing interventions.

Choice C is wrong because vital signs, health history, general survey, and height and weight are not techniques of physical assessment.

They are components of a health assessment, which is a broader term that includes physical assessment as well as other aspects of the patient’s health status.

Choice D is wrong because color is not a technique of physical assessment.

Color is an aspect of inspection, which is one of the techniques of physical assessment.

A. Rhonchi. B. Wheezing. C. Crackles. D. Pleural friction rub.

Correct Answer is A

Explanation

Rhonchi. Rhonchi are low-pitched, rattling sounds that indicate mucus in the larger airways. They are most evident on expiration and may decrease after coughing.

Choice B is wrong because wheezes are high-pitched, squeaking sounds that indicate narrowed small air passages. They are usually heard on both inspiration and expiration.

Choice C is wrong because crackles are short, high-pitched popping sounds that indicate fluid or inflammation in the alveoli. They are usually heard on inspiration.

Choice D is wrong because pleural friction rubs are creaking or grating sounds that indicate inflammation of the pleura. They are usually heard on both inspiration and expiration and do not change with coughing.

View Question and Answer

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to perform a physical assessment. What are the four techniques used?

Correct Answer is B

Explanation

A nurse assessing a client’s lung sounds hears continuous low-pitched harsh rattling sounds over the client’s trachea that are most evident on expiration and are decreased after coughing. Which term is the appropriate choice to accurately document this lung sound?

Correct Answer is A

Explanation

The client has diabetes Type I, a body mass index (BMI) of 17 and poor skin turgor. How should the nurse plan to administer the prescribed. Humulin R 7 units subcutaneously?

A client is learning about diet choices that will increase wound healing after a total knee replacement. What diet selection would indicate that the client understands the correct foods to choose for that outcome to happen?

A nurse is teaching a group of middle age adults about various types of hepatitis. What statement by one of the group members indicates correct understanding of the differences?

The health care provider orders a trough level of an antibiotic administered every twenty four hours. When should the nurse plan for a trough level to be drawn?

Which instruction should a nurse include in the teaching plan for a client receiving non-steroidal anti-inflammatory drugs (NSAIDS) for the treatment of rheumatoid arthritis?

The nurse is assessing a client experiencing acute pain. What assessments should validate the client with acute pain? Select all that apply.

A nurse takes actions to avoid liability when caring for a client with a psychiatric disorder. Which action is not appropriate in the prevention of liability?

A home health nurse is evaluating a health aide for a client with Alzheimer’s Disease. What statement by the health aide would require the nurse to re-evaluate and correct the plan of care?