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)
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Tranylcypromine is a monoamine oxidase inhibitor (MAOI) medication used to treat depression. MAOIs inhibit the activity of the enzyme monoamine oxidase, which helps regulate the breakdown of certain neurotransmitters, including tyramine. Tyramine is typically broken down by monoamine oxidase, but when taking an MAOI, the enzyme's inhibition can lead to an excessive accumulation of tyramine in the body.
Tyramine-rich foods, such as aged cheeses, cured meats, and certain fermented or pickled foods, contain high levels of tyramine. Ingesting these foods while taking an MAOI can lead to a sudden release of stored norepinephrine, causing a hypertensive crisis.
Hypertension is a potentially serious adverse effect of MAOI therapy combined with tyramine-rich food ingestion. Symptoms of a hypertensive crisis can include severe headache, palpitations, chest pain, sweating, blurred vision, and in severe cases, it can lead to stroke or other cardiovascular complications.
Hematuria refers to the presence of blood in the urine and is not a known adverse effect of tranylcypromine or related to tyramine-rich food ingestion.
Tinnitus refers to the perception of ringing or noise in the ears and is not a known adverse effect of tranylcypromine or related to tyramine-rich food ingestion.
Hyperglycemia, or high blood sugar levels, is not a known adverse effect of tranylcypromine or related to tyramine-rich food ingestion. However, it's important to note that tranylcypromine may interact with certain diabetes medications, so it's essential to consider the client's overall medical history and potential drug interactions.
Correct Answer is ["B","C","D"]
Explanation
The correct answers are b, c, and d.
a. It is not appropriate for the nurse to threaten the client's child with reporting for maltreatment without
further assessment and evidence.
b. Asking the client's child to provide details regarding the client's fractured arm will provide additional information about the client's injury and help the nurse assess the potential for abuse or neglect.
c. Discussing respite care options with the client's child may help alleviate any caregiver stress or burden, and ensure the client's continued care and safety.
d. Speaking to the client privately will help establish trust and rapport, and allow the client to disclose any concerns or issues that they may not feel comfortable sharing in front of their child.
e. Providing legal advice regarding power of atorney is not within the scope of nursing practice and should be referred to a legal professional. Additionally, the client's capacity to make decisions and appoint a power of atorney should be assessed before providing such advice.
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