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

Perpetrators of child abuse often exhibit rigid expectations of behavior, demanding strict adherence to rules and may have unrealistic or age-inappropriate expectations for their children. This can lead to increased stress and frustration, which may manifest in abusive behaviors.

Laissez-faire leadership style: A laissez-faire leadership style refers to a hands-off or

non-directive approach, where individuals allow others to make decisions and take control. While this leadership style may have its own implications, it is not specifically associated with child abuse.

Self-blame for financial problems: Self-blame for financial problems may indicate feelings of guilt or personal responsibility for economic difficulties. While financial stress can contribute to increased risk of child abuse, self-blame alone is not a characteristic specific to perpetrators of child abuse.

High self-esteem: High self-esteem refers to a positive self-regard and belief in one's abilities and worth. While low self-esteem can contribute to various psychological issues, including potential difficulties in parenting, high self-esteem is not a characteristic specifically associated with perpetrators of child abuse.

A. Move wounded clients to a safe area before finding shelter. B. Turn cellular phones to silent mode. C. Wave hands to attract the attention of law enforcement. D. Attempt to bargain with the shooter.

Correct Answer is ["B","C"]

Explanation

Turn cellular phones to silent mode: In an active shooter situation, it is crucial to maintain silence to avoid drawing attention to your location. Switching cellular phones to silent mode helps ensure that ringtones or notifications do not alert the shooter to your presence.

Wave hands to attract the attention of law enforcement: When law enforcement or emergency personnel arrive at the scene, it is essential to signal to them that you are not a threat and that you require assistance. This can be done by putting hands up, keeping them visible, and following any instructions provided by law enforcement.

Move wounded clients to a safe area before finding shelter: It is important to prioritize the safety of individuals involved in an active shooter situation. However, moving wounded clients should be done only if it can be done quickly and without putting oneself or others at risk. The primary goal is to seek safety and follow established protocols, such as "run, hide, fight" principles, rather than focusing on moving injured individuals during an ongoing threat.

Attempt to bargain with the shooter: Bargaining or negotiating with an active shooter is strongly discouraged. It is important to remember that the primary goal in an active shooter situation is to ensure personal safety and the safety of others. Engaging with the shooter may escalate the situation or put oneself and others at greater risk.

The in-service should focus on providing staff members with practical guidance on how to respond to an active shooter situation, emphasizing the importance of following established protocols, staying calm, and seeking safety. Additionally, the in-service should include training on recognizing and reporting suspicious behavior, as prevention and early intervention can play a crucial role in mitigating such incidents.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is ["B","C"]

Explanation

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