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A nurse on a medical surgical unit is admitting a client from a provider's office.

Exhibits
Click to highlight the information in the Nurse's Notes and Vital Signs that should be reported to the provider.

1500:                         

  • Temperature: 39 degrees Celcius (102.2 F)
  • Heart rate: 122/min
  • Respiratory rate: 24/min
  • BP: 106/54 mmHg
  • Oxygen saturation: 95% on room air

1530:

  • Client lethargic, reporting abdominal cramping, experiencing projectile vomiting.
  • Voiding dark, concentrated urine.
  • Client requesting water

A.

Temperature: 39 degrees Celcius (102.2 F)

B.

Heart rate: 122/min

C.

Respiratory rate: 24/min

D.

BP: 106/54 mmHg

E.

Oxygen saturation: 95% on room air

F.

Client lethargic, reporting abdominal cramping, experiencing projectile vomiting.

G.

Voiding dark, concentrated urine.

H.

Client requesting water

Answer and Explanation

The Correct Answer is ["A","B","D","F","G","H"]

Vital Signs

  • Temperature: 39°C (102.2°F) → fever worsened since admission (sign of possible infection).
     
  • Heart rate: 122/min → tachycardia, worsened compared to earlier.
     
  • Blood pressure: 106/54 mmHg → trending downward, may indicate fluid deficit/hypotension risk.

Nurse’s Notes

  • Client lethargic → worsening mental status.
     
  • Projectile vomiting → new onset, risk of dehydration and electrolyte imbalance.
     
  • Abdominal cramping → possible gastrointestinal complication.
     
  • Voiding dark, concentrated urine → sign of dehydration.
     
  • Client requesting water → excessive thirst consistent with hyperglycemia/possible hyperosmolar state.


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Related Questions

Correct Answer is ["A","C","E"]

Explanation

Rationale:

  • Retaining the fluid allows the enema to soften stool and stimulate peristalsis effectively.
  • Avoiding frequent use prevents dependence and irritation of the bowel.
  • Following provider instructions ensures safe and appropriate selection of enema type and solution for the client’s condition.
  • Electrolyte imbalances, benefits of solutions, and fluid intake are important considerations but are broader teaching points, not immediate enema administration instructions.

Correct Answer is ["A","C","D"]

Explanation

Rationale:

  • Diarrhea is one of the most frequent gastrointestinal side effects of antibiotics due to alteration of normal intestinal flora and increased motility.
  • Nausea is a common adverse reaction as antibiotics can irritate the stomach lining or affect gut motility.
  • Abdominal pain may occur secondary to irritation of the gastrointestinal tract or as part of antibiotic-associated colitis.
  • Clostridium difficile infections are a serious complication, not a routine side effect, requiring immediate evaluation and intervention.
  • Vomiting may occur but is less common compared to nausea and diarrhea.
  • Loss of healthy bacteria is the underlying mechanism of many side effects, but it is not typically described to clients as a direct side effect.

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