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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 B

Explanation

Rationale:
A. Clients with hepatitis often experience anorexia and nausea. Small, frequent meals are better tolerated than three large meals.
B. Carbohydrates are the primary source of calories in clients with hepatitis. They help spare protein and allow the liver to rest and heal. This is the recommended dietary intervention.
C. Protein should be limited in clients with severe hepatitis, especially if liver function is impaired, because excess protein can worsen encephalopathy.
D. Acetaminophen is hepatotoxic and should be avoided in clients with hepatitis due to the risk of further liver damage.

Correct Answer is D

Explanation

Rationale:
A. Celery and other high-fiber, coarse vegetables should be avoided during an acute diverticulitis episode because they can irritate the inflamed colon.
B. Green peas are high in fiber and may worsen symptoms during acute inflammation.
C. Green salad is high in fiber and not recommended during an acute flare.
D. Grilled chicken breast with white rice is low in fiber, easily digestible, and gentle on the gastrointestinal tract, making it appropriate for a client with acute diverticulitis.

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