A nurse is monitoring a client who recently had an esophagogastroduodenoscopy procedure. Which of the following findings should the nurse Identify as an indication that the client is recovering after the procedure as expected?
Temperature 38.7° C (101.7° F)
Heart rate 110/min
Respiratory rate 14/min
Spo2 92%
The Correct Answer is C
A. Temperature 38.7° C (101.7° F): A temperature of 38.7° C (101.7° F) is elevated and may indicate an infection or inflammation, which is not expected after an EGD. A mild fever could occur briefly, but temperatures above 100.4° F should be monitored closely.
B. Heart rate 110/min: A heart rate of 110/min is elevated and may suggest tachycardia due to pain, anxiety, or potential complications. An elevated heart rate should be assessed further, as it is not typical during the recovery phase of an EGD procedure.
C. Respiratory rate 14/min: A respiratory rate of 14/min is within the normal range for an adult (12-20/min), indicating that the client is breathing comfortably and is recovering well from the procedure. This is an expected finding post-procedure.
D. SpO2 92%: An SpO2 level of 92% is slightly low. The normal range for oxygen saturation is typically 95-100%, and a reading of 92% may indicate mild hypoxemia, which should be further evaluated, especially if the client is recovering from sedation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Bilateral coarse, crackle breath sounds: These are common findings in pulmonary edema due to fluid accumulation in the lungs. Furosemide, a diuretic, helps reduce fluid overload, making it an appropriate medication to help improve these symptoms by promoting diuresis.
B. Vesicular breath sounds over the peripheral lung fields: Vesicular breath sounds are normal, and do not indicate the need for diuretics. The prescription for furosemide would be more appropriate if the client had signs of fluid overload, such as crackles.
C. Potassium 3.2 mEq/L (3.5 mEq/L to 5.0 mEq/L): This indicates hypokalemia. Since furosemide can cause potassium depletion, the nurse should verify the prescription and monitor the client’s potassium levels closely, as additional supplementation may be needed.
D. Blood pressure 100/70 mm Hg: This blood pressure is on the lower side of normal. While furosemide can lower blood pressure, this finding alone doesn't specifically indicate that the pulmonary edema is being effectively treated.
Correct Answer is B
Explanation
A. "Restrict your partner's oral fluid intake to 450 mL/day.": Fluid restriction in ESKD should be individualized based on the client’s kidney function and retention. A strict 450 mL/day limit is not universally applicable.
B. "Limit your partner's potassium intake to 60 mEq/L per day.": Potassium intake is typically restricted in ESKD due to the kidneys' reduced ability to excrete it. The appropriate restriction depends on potassium levels, but generally, it’s advised to limit intake to prevent hyperkalemia and related complications.
C. "Help your partner consume foods containing phosphorus.": Phosphorus intake should be restricted in ESKD, as high phosphorus levels can cause complications like bone disease. Consuming phosphorus-rich foods should be avoided to prevent calcium-phosphorus imbalances and calcification.
D. "Encourage foods high in protein for your partner.": Excess protein intake in ESKD can exacerbate kidney function decline and increase waste buildup. Protein intake should be monitored and reduced to minimize the kidneys’ workload and prevent further damage.
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