A nurse is caring for a client who has gastroenteritis and is reviewing the client's findings from two days ago and today. Which of the following findings require immediate follow-up?
The client is confused and appears weak.
The client's oral mucosa is dry and tongue is furrowed.
The client's temperature is 37.4° C (99.3° F).
The client's blood pressure is 90/58 mm Hg.
The Correct Answer is A
Choice A reason: Confusion and weakness are signs of dehydration and electrolyte imbalance, which can result from vomiting and diarrhea. These are serious complications that can affect the client's mental status, blood pressure, heart rate, and kidney function. The nurse should report these findings to the provider and monitor the client's vital signs and fluid status.
Choice B reason: Dry oral mucosa and furrowed tongue are also signs of dehydration, but they are less severe than confusion and weakness. The nurse should report these findings to the provider as well, but they are not the most urgent ones.
Choice C reason: A temperature of 37.4° C (99.3° F) is slightly elevated, but not indicative of a fever or infection. The nurse should document this finding, but it does not require immediate follow-up.
Choice D reason: A blood pressure of 90/58 mm Hg is low, but not hypotensive. The nurse should document this finding, but it does not require immediate follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Peas are not a good choice for a mechanical soft diet, as they are small and round and can pose a choking hazard. Peas also require some chewing to break them down, which may be difficult for the client.
Choice B reason: Dried apricots are not a good choice for a mechanical soft diet, as they are hard and sticky and can damage the teeth or dentures. Dried apricots also require a lot of chewing to swallow them, which may be painful or tiring for the client.
Choice C reason: Canned pears are a good choice for a mechanical soft diet, as they are soft and moist and can be easily mashed with a fork. Canned pears do not require much chewing and can be swallowed smoothly.
Choice D reason: Cashews are not a good choice for a mechanical soft diet, as they are hard and crunchy and can injure the gums or oral mucosa. Cashews also require a lot of chewing and can get stuck in the teeth or dentures.
Correct Answer is B
Explanation
Choice A reason: Measuring the client's gastric residual every 12 hr is not frequent enough to monitor the feeding tolerance and prevent aspiration. The nurse should measure the gastric residual before each intermittent feeding or every 4 to 6 hr during continuous feeding¹².
Choice B reason: Flushing the client's tube with 30 mL of water every 4 hr is an appropriate action to maintain the tube patency, prevent clogging, and hydrate the client. The nurse should flush the tube before and after each medication administration, feeding, or gastric residual check¹³.
Choice C reason: Keeping the client's head elevated at 15° during feedings is not sufficient to prevent reflux and aspiration. The nurse should elevate the head of the bed at least 30° to 45° during feedings and for at least 30 min to 1 hr after feedings¹⁴.
Choice D reason: Obtaining the client's electrolyte levels every 4 hr is not necessary unless the client has signs of fluid or electrolyte imbalance, such as edema, dehydration, or abnormal vital signs. The nurse should monitor the client's weight, intake and output, and laboratory values as ordered by the provider¹⁵.
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.