A nurse is collecting data from a client who is 12 hr postoperative following intestinal surgery. Which of the following findings should the nurse report to the charge nurse prior to client ambulation?

Oxygen saturation 90%

Respiratory rate 20/min

Apical pulse rate 88/min

Oral temperature 37.6° C (99.7° F)

Answer and Explanation

The Correct Answer is A

An oxygen saturation level of 90% is below the normal range and indicates inadequate oxygenation. This finding could indicate respiratory compromise or impaired lung function, which may require further assessment and intervention before allowing the client to ambulate.

The respiratory rate of 20 breaths per minute, apical pulse rate of 88 beats per minute, and oral temperature of 37.6°C (99.7°F) are within the expected range and do not raise immediate concerns that require reporting to the charge nurse prior to ambulation.

However, the nurse should continue to monitor these vital signs during and after ambulation to ensure stability.

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Correct Answer is C

Explanation

Roasted Salmon

The nurse should include roasted salmon on the tray for the client who follows a kosher diet.

Kosher dietary laws prohibit the consumption of shellfish such as clams and shrimp, as well as pork products like pulled pork sandwiches. Roasted salmon, on the other hand, is a permissible food item in a kosher diet.

It's important for the nurse to be aware of the client's dietary restrictions and preferences to ensure that they receive appropriate and culturally sensitive care.

A. 2+ pedal edema B. Jaundice C. Nuchal rigidity D. Hematuria

Correct Answer is C

Explanation

Bacterial meningitis is a serious infection of the membranes surrounding the brain and spinal cord that can cause inflammation and damage to the nervous system.

Nuchal rigidity refers to stiffness and pain in the neck that makes it difficult to flex the neck forward. This finding is indicative of inflammation of the meninges and is a classic sign of meningitis.

Pedal edema refers to swelling of the feet and ankles and can be caused by various conditions such as heart, liver, or kidney problems.

Jaundice refers to yellowing of the skin and eyes and can be caused by liver or bile duct disease.

Hematuria refers to the presence of blood in the urine and can be caused by various conditions such as urinary tract infections, kidney stones, or bladder cancer. These findings are not related to bacterial meningitis and may suggest other health concerns that require further evaluation and management.

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A nurse is collecting data from a client who is 12 hr postoperative following intestinal surgery. Which of the following findings should the nurse report to the charge nurse prior to client ambulation?

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