A nurse is caring for a client who is postoperative following an appendectomy.
Vital Signs 1800:
Temperature 98.4° F (36.8° C) Heart rate 104/min
Respiratory rate 22/min
Blood pressure 142/80 mm Hg O2 saturation 97% on room air 1800:
Client alert and oriented x 4
Skin warm and dry
Lungs clear on auscultation
Bowel sounds hypoactive in all four quadrants Urine clear yellow
Incisional dressing clean and dry
Client reports pain as 6 on a scale of 0 to 10
1815:
Morphine administered as prescribed
2000:
Temperature 98.4° F (36.8° C) Heart rate 110/min Respiratory rate 24/min
Blood pressure 158/88 mm Hg O2 saturation 93% on room air.
Which of the following 4 client findings should the nurse report to the provider?
Bowel sounds
Oxygen saturation
Nausea
Vomiting
Pain level
Heart rate
Incision characteristics
Lungs sounds
Correct Answer : B,C,E,F
- A. Bowel sounds are hypoactive in all four quadrants, which is expected after an appendectomy due to anesthesia and decreased peristalsis. This is not a finding that needs to be reported to the provider.
- B. Oxygen saturation is 93% on room air, which is below the normal range of 95% to 100%. This could indicate impaired gas exchange, respiratory depression, or infection. This is a finding that needs to be reported to the provider.
- C. Nausea is a common feature of appendicitis and should go away with appendectomy. This finding should, therefore, be reported to the healthcare provider.
- D. Vomiting is also a common side effect of morphine and anesthesia, and can be managed with antiemetics and fluids. This is not a finding that needs to be reported to the provider unless it persists or interferes with oral intake.
- E. Pain level is 6 on a scale of 0 to 10. The client received morphine as prescribed at 1815, and the pain level is still significant. This is a finding that needs to be reported to the provider
- F. Heart rate is 110/min, which is above the normal range of 60 to 100/min. This could indicate pain, anxiety, dehydration, infection, or bleeding. This is a finding that needs to be reported to the provider.
- G. Incision characteristics are clean and dry, which is expected after an appendectomy. However, the nurse should monitor for signs of infection such as redness, swelling, warmth, drainage, or odor. This is a finding that needs to be reported to the provider if any signs of infection are present.
- H. Lungs sounds are clear on auscultation, which is expected after an appendectomy. However, the nurse should encourage deep breathing and coughing exercises to prevent atelectasis and pneumonia. This is a finding that needs to be reported to the provider if any abnormal lung sounds are heard such as crackles, wheezes, or diminished breath sounds.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Limiting fluid intake to 1 liter per day can lead to dehydration and other health complications. It is important for the client to maintain adequate hydration, especially postpartum. This option is incorrect and potentially harmful.
Choice B rationale:
Manual expression of milk can help relieve engorgement without stimulating further milk production. This method allows the client to express milk as needed. However, it can be done even before engorgment occurs
Choice C rationale:
Wearing a snug-fitting bra can provide support and comfort.
Choice D rationale:
Applying moist heat to the breasts can stimulate milk production and relieve engorgement. However, in this case, the client wants to suppress lactation. Therefore, this option is not appropriate and may have the opposite effect of increasing milk production.
Correct Answer is B
Explanation
- A. This choice is incorrect because forgetting to buy a gift is not an example of dissociation, but rather a sign of poor memory or lack of attention.
- B. This choice is correct because describing the abuse as if it happened to someone else is an example of dissociation, which is a defense mechanism that involves separating oneself from painful or traumatic experiences.
- C. This choice is incorrect because being verbally assertive is not an example of dissociation, but rather a personality trait or a coping skill.
- D. This choice is incorrect because blaming the boss for not getting a promotion is not an example of dissociation, but rather a sign of external locus of control or rationalization.
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