Assessment findings for a client following a colectomy for familial polyposis include an ileostomy bag that contains a large amount of fecal liquid and an IV infusion of dextrose 5% in lactated Ringer's infusing at a rate of 100 mL/hour. Which assessment is most

Urinary output.

Serum electrolytes.

Peristomal skin integrity.

Skin turgor.

Answer and Explanation

The Correct Answer is B

A.   While monitoring urinary output is important, it is not the most critical assessment in this context.
B.   Monitoring serum electrolytes is crucial because the large amount of fecal liquid output from the ileostomy can lead to significant electrolyte imbalances.
C.   Peristomal skin integrity is important but is secondary to the immediate risk of electrolyte imbalances.
D.   Skin turgor is important for assessing hydration status, but monitoring electrolytes is more directly related to the immediate postoperative care.

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Correct Answer is B

Explanation

A. Level of consciousness is not directly related to the risk of OSAS.

B. Body mass index (BMI) is a significant risk factor for OSAS, as higher BMI is strongly associated with increased risk of sleep apnea.

C. Self-description of pain does not relate to the risk factors for OSAS.

D. Breath sounds might be relevant in assessing respiratory status but do not directly indicate the risk for OSAS.

A. Heart rate 121 beats/minute B. Capillary refill 2 seconds C. Respirations 28 breaths/minute with shallow breathing D. Radial and pedal pulses 2+ E. Severe abdominal pain in right lower quadrant F. Feels anxious G. Temperature 100.8° F (38.2° C) H. Vomiting small amounts of green bile I. Blood pressure 115/76 mm Hg

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

Explanation

A. Tachycardia indicates the body is responding to pain, infection, or potential sepsis. It's a critical vital sign indicating the body's stress response.
B. Tachypnea can be a response to pain or anxiety but also indicates the need for careful monitoring of respiratory status, especially postoperatively.

C. A capillary refill of 2 seconds is within the normal range and indicates adequate peripheral perfusion.
D. Radial and pedal pulses 2+ are within the normal range and indicates adequate peripheral perfusion.
E. Severe abdominal pain in the right lower quadrant is a primary symptom of appendicitis, which is confirmed by the CT scan showing a dilated appendix and fat stranding. Immediate attention is needed to address potential complications such as rupture.
F. Feeling anxious needs to be managed to promote patient comfort. However, it doesn’t need to be managed immediately since it is not life-threatening.
G. Fever is a sign of infection or inflammation, common in appendicitis. Monitoring and managing fever is crucial in preventing further complications.
H. Bilious vomitus is a common finding in appendicitis and may indicate that the inflammation has progressed to a point where it is causing a blockage in the intestines. This obstruction can lead to increased pressure within the abdominal cavity and compromise blood flow, potentially resulting in a life-threatening situation.
I. A blood pressure of 115/76 mm Hg is within normal limits and indicates stable hemodynamics at this point.

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Assessment findings for a client following a colectomy for familial polyposis include an ileostomy bag that contains a large amount of fecal liquid and an IV infusion of dextrose 5% in lactated Ringer's infusing at a rate of 100 mL/hour. Which assessment is most

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Naxlex Comprehensive Predictor Exams

Which information is most important for the nurse to obtain when determining a client's risk for obstructive sleep apnea syndrome (OSAS)?

Correct Answer is B

Explanation

Exhibits The nurse is caring for the client. Which of the following assessment findings should the nurse prioritize?

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

Explanation

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