During a two-week postoperative follow-up home visit, a client who had gastric bypass surgery exhibits abdominal tenderness, shoulder pain, and feelings of malaise.
The client’s vital signs are an oral temperature of 101.80F (38.8° C), a blood pressure of 100/50 mm Hg, a heart rate of 104 beats/minute, and a respiratory rate of 18 breaths/minute.
What is the appropriate action for the nurse to take?
Recheck the client’s vital signs in 30 minutes.
Have the client transported via ambulance to the hospital.
Determine the client’s current oxygen saturation rate.
Instruct the client to drive to the hospital for admission.
The Correct Answer is B
Answer and explanation
The correct answer is Choice B.
Choice A rationale
Rechecking the client’s vital signs in 30 minutes may not be the most appropriate action in this situation. The client is showing signs of possible complications such as infection (elevated
temperature, malaise) and referred pain in the shoulder, which could indicate diaphragmatic irritation. These symptoms, along with the client’s recent surgery, suggest that immediate medical attention may be necessary.
Choice B rationale
Having the client transported via ambulance to the hospital is the most appropriate action. The client’s symptoms suggest possible complications that require immediate medical attention.
Abdominal tenderness and shoulder pain could indicate a serious condition such as a perforation or infection. The elevated heart rate and low blood pressure could suggest sepsis or shock. Immediate medical evaluation and treatment are necessary.
Choice C rationale
Determining the client’s current oxygen saturation rate is important, but it is not the most immediate need. While this information could provide additional data about the client’s condition, it does not address the potential seriousness of the client’s symptoms. The client needs immediate medical attention.
Choice D rationale
Instructing the client to drive to the hospital for admission is not the best choice. Given the client’s symptoms and recent surgery, it would be safer for the client to be transported by ambulance. This would ensure that the client receives immediate medical attention and that the client’s condition can be monitored during transport.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Answer and explanation
The correct answer is Choice B.
Choice A rationale
While reinforcing instructions can boost a patient’s self-confidence, it may not be effective for an elderly patient with Parkinson’s disease who is unable to administer ophthalmic medication due to hand tremors. The physical limitation caused by the tremors may not be overcome by further instruction.
Choice B rationale
If a family member is available and willing to administer the medication, this could be an effective solution. The family member can be trained to administer the medication correctly, ensuring the patient receives their necessary treatment.
Choice C rationale
While obtaining a prescription for a visiting nurse to administer the medication twice a day could ensure the patient receives their medication, it may not be the most practical or cost- effective solution. It also depends on the availability of such services in the patient’s area.
Choice D rationale
Documenting the patient’s inability to administer the medication without assistance is important for record-keeping and communicating with other healthcare providers. However, it does not address the immediate issue of ensuring the patient receives their necessary medication.
Correct Answer is C
Explanation
Answer and explanation The correct answer is C. Choice A rationale
While the dissemination of all educational pamphlets among the served counties indicates successful distribution of information, it does not necessarily reflect a change in health outcomes or behaviors.
Choice B rationale
Although a high rating from workshop attendees indicates that the program was well-received, it does not provide measurable health outcomes.
Choice C rationale
A decrease in cardiac-related fatalities by 109% six months after the program’s presentation is a direct and measurable outcome that indicates the program was successful in its goal to prevent strokes and acute coronary syndrome.
Choice D rationale
While a commitment to adopting a healthier lifestyle from 65% of the program’s participants is a positive outcome, it is based on self-report and does not provide direct evidence of a decrease in strokes or acute coronary syndrome.
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