A nurse is obtaining a client's vital signs. Which of the following findings should the nurse report to the charge nurse?

Heart rate 98/min

Temperature 38.0 °C (100.4 °F)

Respiratory rate 14/min

Blood pressure 142/88 mm Hg

Answer and Explanation

The Correct Answer is B

A. Heart rate 98/min. A heart rate of 98 beats per minute is within the normal range for adults, which is typically between 60 and 100 beats per minute. Therefore, this finding does not require reporting.
B. Temperature 38.0 °C (100.4 °F). A temperature of 38.0 °C (100.4 °F) is considered a low-grade fever and may indicate an infection or other underlying condition. This finding should be reported to the charge nurse for further assessment and potential intervention.
C. Respiratory rate 14/min. A respiratory rate of 14 breaths per minute is within the normal range for adults, which is generally between 12 and 20 breaths per minute. This finding does not require reporting.
D. Blood pressure 142/88 mm Hg. A blood pressure reading of 142/88 mm Hg is classified as elevated or stage 1 hypertension. While it is important to monitor blood pressure, this finding may not require immediate reporting unless there are additional concerning symptoms or a significant change from the client's baseline readings.

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Correct Answer is C

Explanation

A. "Occasional small clots in the urine." Small clots in the urine can be expected in the first 24 to 48 hours following a vaginal hysterectomy due to minor bleeding from surgical manipulation. However, large or persistent clots should be reported as they may indicate active bleeding.
B. "Frequent urge to urinate." A frequent urge to urinate is common after surgery due to bladder irritation, inflammation, or the effects of anesthesia. However, if accompanied by pain, burning, or difficulty urinating, it could indicate a urinary tract infection or urinary retention requiring further evaluation.
C. "Dark red urine." Dark red urine suggests active bleeding, which is not an expected postoperative finding and requires immediate evaluation. This may indicate excessive surgical site bleeding or trauma to the urinary tract, necessitating prompt intervention by the provider.
D. "Urine output of 300 mL over 8 hr." While this is lower than the expected urine output (at least 30 mL/hr or 240 mL in 8 hours), it is not critically low. The nurse should encourage fluid intake and monitor for signs of dehydration or urinary retention before escalating the concern to the provider.

A. Cottage cheese B. Bran muffin C. Tomato juice D. Puffed rice cereal

Correct Answer is B

Explanation

A. Cottage cheese: Cottage cheese is low in fiber and does not promote bowel regularity. A diet high in fiber is recommended to help soften stool and stimulate peristalsis, which is necessary for relieving constipation.
B. Bran muffin: Bran is an excellent source of dietary fiber, which adds bulk to stool and facilitates easier bowel movements. High-fiber foods, such as whole grains, fruits, and vegetables, are essential in managing constipation effectively.
C. Tomato juice: While tomato juice contains some nutrients, it is not a significant source of fiber. Increasing fiber intake is more beneficial for constipation than consuming low-fiber liquids. However, adequate hydration is still important in preventing hard stools.
D. Puffed rice cereal: Puffed rice cereal is typically refined and low in fiber, making it a poor choice for relieving constipation. Whole grains, such as bran, oatmeal, or whole wheat products, are more effective in promoting bowel regularity.

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A nurse is obtaining a client's vital signs. Which of the following findings should the nurse report to the charge nurse?

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