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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
30 mL. This is because one ounce is equal to 29.57353 milliliters, so one ounce of an elixir medication is approximately 30 milliliters.
The nurse should instruct the client to take 30 milliliters of the medication during discharge teaching.
Choice A is wrong because 5 milliliters is much less than one ounce. Choice B is wrong because 15 milliliters is half of one ounce.
Choice C is wrong because 25 milliliters is slightly less than one ounce.
The nurse should use a conversion factor or a calculator to convert ounces to milliliters accurately.
Correct Answer is C
Explanation
This is because hepatitis C is a viral infection that spreads through contaminated blood and body fluids. IV drug use is one of the most common ways to get hepatitis C, especially if people share needles or other equipment.
Choice A is wrong because drinking contaminated water is not a risk factor for hepatitis
C. Hepatitis A and E are transmitted by the fecal-oral route, which can happen through contaminated water.
Choice B is wrong because eating raw chicken is not a risk factor for hepatitis C. Hepatitis E can be transmitted by eating undercooked meat from infected animals, but not chicken.
Choice D is wrong because unprotected intercourse is not a major risk factor for hepatitis
C. Hepatitis B and D are more likely to be transmitted by sexual contact than hepatitis
C. However, having multiple sexual partners or having sexually transmitted diseases can increase the risk of hepatitis
C. Normal ranges for hepatitis C tests depend on the type of test and the laboratory that performs it.
Some common tests are:
- Anti-HCV antibody test: This test detects antibodies to the hepatitis C virus in the blood.
A positive result means that the person has been exposed to the virus, but does not necessarily mean that they have an active infection. A negative result means that the person has never been exposed to the virus or has cleared it from their body.
- HCV RNA test: This test measures the amount of hepatitis C virus in the blood.
A positive result means that the person has an active infection and can transmit the virus to others. A negative result means that the person does not have an active infection or has cleared it from their body.
- HCV genotype test: This test identifies the strain or type of hepatitis C virus that the person has. There are six major genotypes of hepatitis C, numbered 1 to 6, and each one may respond differently to treatment.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.