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A nurse on a medical-surgical unit is reviewing the electronic health record of a client who is being admitted from the emergency department.

Exhibits

After reviewing the client's EHR, which of the following client's findings require further follow-up by the nurse?

Click to highlight the client's findings that require further follow-up by the nurse. To deselect a finding, click on the finding again.

Body System

Findings

Gastrointestinal

Client reports abdominal pain as a 9 on a pain scale of 0 to 10.

Abdomen is distended and firm.

Bowels sounds are distant and hypoactive.

Integumentary

Skin is warm and dry.

Perianal skin is excoriated, and small ulceration is noted.

Fluid balance

Tenting of skin for 4 seconds is noted.

Capillary refill is 2 seconds.

Temperature 38.7° C (101.7° F)

Mucous membranes are dry.

Respiratory rate 20/min

Client reports abdominal pain as a 9 on a pain scale of 0 to 10

Abdomen is distended and firm

Bowels sounds are distant and hypoactive

Skin is warm and dry

Perianal skin is excoriated, and small ulceration is noted

Tenting of skin for 4 seconds is noted

Capillary refill is 2 seconds

Temperature 38.7° C (101.7° F)

Mucous membranes are dry

Respiratory rate 20/min

Answer and Explanation

The Correct Answer is ["A","B","C","E","F","H","I"]

Rationale for Correct Choices:
• Client reports abdominal pain as a 9 on a pain scale of 0 to 10: Severe abdominal pain indicates significant underlying pathology. In the presence of vomiting, distention, and altered bowel sounds, it could reflect obstruction, ischemia, or peritonitis, requiring urgent intervention.

• Abdomen is distended and firm: Distention and firmness suggest accumulation of gas or fluid within the abdomen. This is concerning for bowel obstruction or peritonitis, which can compromise circulation and lead to sepsis if untreated.

• Bowel sounds are distant and hypoactive: Diminished bowel sounds point to decreased peristalsis. In a client with abdominal pain and distention, this strongly suggests obstruction or ileus, requiring prompt diagnostic and therapeutic measures.

• Perianal skin is excoriated, and small ulceration is noted: Frequent diarrhea has led to skin breakdown and ulceration. This not only causes pain and discomfort but also increases the risk of secondary infection, requiring local wound care and protection.

• Tenting of skin for 4 seconds is noted: Delayed skin turgor indicates poor hydration status. Given this client’s vomiting, diarrhea, and low oral intake, this is a strong indicator of fluid volume deficit needing IV replacement.

• Temperature 38.7 °C (101.7 °F): Fever signals the presence of infection. With gastrointestinal complaints, this may be due to bacterial gastroenteritis, abscess formation, or other intra-abdominal infection that warrants further evaluation.

• Mucous membranes are dry: Dry mucous membranes reflect fluid volume depletion. This is consistent with the client’s history of poor intake, vomiting, and diarrhea, and further confirms dehydration.

Rationale for Incorrect Choices:

• Skin is warm and dry: Warm, dry skin suggests adequate peripheral perfusion and does not require follow-up compared to more urgent findings like dehydration and abdominal changes.

• Capillary refill is 2 seconds: A refill time under 3 seconds indicates sufficient peripheral circulation. This finding is within normal limits and does not require additional intervention.

• Respiratory rate 20/min: A respiratory rate within the range of 12–20 breaths/min is considered normal for adults. This shows stable respiratory function and does not require follow-up.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Assist the client in making decisions about the need for life support: Nurses can provide education about treatment options, but making decisions about life support is the client’s responsibility, often in consultation with their provider.

B. Notify the provider of the client's durable power of attorney for health care: While important in care planning, notifying the provider is not the nurse’s primary responsibility under the PSDA. The act requires that clients be asked about advance directives and informed of their rights first.

C. Clarify the legal competency of the client: Determining legal competency is a responsibility of the courts, not nurses. Nurses assess decision-making capacity, but under the PSDA, the main role is to ask and provide information about advance directives.

D. Ask the client whether they have created advance directives: The PSDA requires healthcare institutions to inform clients of their right to make decisions regarding their care, including the right to have advance directives. Asking about existing directives fulfills the nurse’s obligation under this law.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

Rationale for correct choices:

Pneumonia: The client has an elevated temperature, productive cough with thick white mucus, and mild crackles in the upper lobes. These findings, combined with recent immobility after surgery, indicate pulmonary infection risk.
Respiratory findings: Crackles, cough, and sputum production directly support pneumonia as the complication most consistent with the client’s presentation.

Rationale for incorrect choices:

Deep vein thrombosis: Although the client has nonpitting edema in the right leg, distal circulation is intact (pedal pulse 2+, capillary refill <2 seconds, foot warm). No calf pain, erythema, or unilateral swelling progression is reported.
Urinary tract infection: The client voided a large amount of amber urine without dysuria, urgency, or suprapubic discomfort. No urinary abnormalities have been noted to suggest UTI.
Nonpitting edema: This finding is expected locally after knee arthroplasty and does not indicate systemic infection.
Elevated temperature: Fever alone is nonspecific and could be related to multiple postoperative risks; the respiratory findings provide more precise evidence for pneumonia.

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Body System	Findings
Gastrointestinal	Client reports abdominal pain as a 9 on a pain scale of 0 to 10. Abdomen is distended and firm. Bowels sounds are distant and hypoactive.
Integumentary	Skin is warm and dry. Perianal skin is excoriated, and small ulceration is noted.
Fluid balance	Tenting of skin for 4 seconds is noted. Capillary refill is 2 seconds. Temperature 38.7° C (101.7° F) Mucous membranes are dry. Respiratory rate 20/min

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who is to undergo a surgical procedure. Under the Patient Self-Determination Act (PSDA), which of the following actions is the nurse's responsibility regarding the client's advance directives?

Correct Answer is D

Explanation

A nurse is monitoring a client for complications following surgery. Exhibits Complete the following sentence by using the lists of options. The client is at greatest risk for developing dropdownas evidenced bydropdown.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

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