A nurse on a medical-surgical unit is assisting in the care of a male client.
Exhibits
Which of the following findings indicate a need for follow-up by the nurse?
Select all that apply.
Temperature
Heart rate
Skin findings
Respiratory rate
Oxygen saturation
Blood pressure
Urinary output
Correct Answer : B,F,G
A. Temperature: The temperature remains stable and within normal limits. A postoperative temperature range of 36.3° C (97.3° F) to 36.4° C (97.5° F) is not indicative of infection or other complications at this time.
B. Heart rate: The heart rate has increased from 84/min to 104/min, indicating sinus tachycardia. This could be a compensatory response to decreased blood volume or another underlying issue, necessitating further assessment.
C. Skin findings: The skin findings are described as warm and dry, which is normal. No abnormalities are noted, so this does not require follow-up.
D. Respiratory rate: The respiratory rate has increased slightly to 24/min but is not significantly abnormal. This may not be a priority for follow-up unless other symptoms are present.
E. Oxygen saturation: The oxygen saturation is within normal limits (96% on room air), suggesting adequate oxygenation. No immediate concerns are evident based on this measurement.
F. Blood pressure: The blood pressure has dropped from 106/74 mm Hg to 88/54 mm Hg, indicating possible hypotension. This drop could signal hypovolemia or bleeding, requiring prompt follow-up to investigate the cause.
G. Urinary output: The urinary output of 110 mL over 6 hours is low, which might indicate dehydration or renal issues. Monitoring and addressing this finding are important to ensure adequate fluid balance and kidney function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I would like to see what this looks like today": This indicates effective coping as the client is engaging with their condition and facing the changes directly, which is an important step in emotional adjustment and recovery.
B. "I'm going to close my eyes until you are done dressing my incision": This suggests avoidance of the situation, which may indicate difficulty in coping with the reality of their condition.
C. "I would just like to spend my day staring at the TV": This may indicate withdrawal or avoidance, which is not an effective coping strategy.
D. "I'm planning to stay at home until my breast reconstructive surgery": While this may be part of the client's plan, it does not directly indicate effective coping with the current situation.
Correct Answer is D
Explanation
A. Take the medication right before eating breakfast: Alendronate should be taken first thing in the morning on an empty stomach, at least 30 minutes before eating or drinking anything. This helps maximize absorption and reduce the risk of esophageal irritation.
B. Chew the tablets thoroughly: Alendronate tablets should not be chewed. They must be swallowed whole to ensure proper delivery and absorption.
C. Drink milk with the medication: Milk can interfere with the absorption of alendronate. It is advised to take the medication with plain water only.
D. Sit upright for 30 to 60 min after taking the medication: This is correct as sitting upright helps prevent esophageal irritation and facilitates the medication's passage into the stomach.
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