A nurse is caring for a client who is postoperative following an appendectomy.
Vital Signs
1800:
Temperature 98.4° F (36.8° C) Heart rate 104/min
Respiratory rate 22/min
Blood pressure 142/80 mm Hg
O2 saturation 97% on room air
1800:
Client alert and oriented x 4
Skin warm and dry
Lungs clear on auscultation
Bowel sounds hypoactive in all four quadrants Urine clear yellow
Incisional dressing clean and dry
Client reports pain as 6 on a scale of 0 to 10
1815:
Morphine administered as prescribed
2000:
Temperature 98.4° F (36.8° C) Heart rate 110/min Respiratory rate 24/min
Blood pressure 158/88 mm Hg O2 saturation 93% on room air
Which of the following 4 client findings should the nurse report to the provider?
Bowel sounds
Oxygen saturation
Nausea
Vomiting
Pain level
Heart rate
Incision characteristics
Lungs sounds
Correct Answer : B,F,G,H
A. Bowel sounds are hypoactive in all four quadrants, which is expected after an appendectomy due to anesthesia and decreased peristalsis. This is not a finding that needs to be reported to the provider.
B. Oxygen saturation is 93% on room air, which is below the normal range of 95% to 100%. This could indicate impaired gas exchange, respiratory depression, or infection. This is a finding that needs to be reported to the provider.
C. Nausea is a common side effect of morphine and anesthesia, and can be managed with antiemetics and fluids. This is not a finding that needs to be reported to the provider unless it persists or interferes with oral intake.
D. Vomiting is also a common side effect of morphine and anesthesia, and can be managed with antiemetics and fluids. This is not a finding that needs to be reported to the provider unless it persists or interferes with oral intake.
E. Pain level is 6 on a scale of 0 to 10, which is moderate pain. The client received morphine as prescribed at 1815, and the pain level should be reassessed after 30 minutes. This is not a finding that needs to be reported to the provider unless the pain is unrelieved or increases.
- F. Heart rate is 110/min, which is above the normal range of 60 to 100/min. This could indicate pain, anxiety, dehydration, infection, or bleeding. This is a finding that needs to be reported to the provider.
- G. Incision characteristics are clean and dry, which is expected after an appendectomy. However, the nurse should monitor for signs of infection such as redness, swelling, warmth, drainage, or odor. This is a finding that needs to be reported to the provider if any signs of infection are present.
- H. Lungs sounds are clear on auscultation, which is expected after an appendectomy. However, the nurse should encourage deep breathing and coughing exercises to prevent atelectasis and pneumonia. This is a finding that needs to be reported to the provider if any abnormal lung sounds are heard such as crackles, wheezes, or diminished breath sounds.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
- Seizure precautions are measures taken to protect a client who is at risk of having a seizure, which is a sudden and abnormal electrical activity in the brain that can cause changes in behavior, movement, sensation, or consciousness. Seizure precautions include providing a safe environment, monitoring the client's vital signs and neurological status, administering anticonvulsant medications, and documenting the onset, duration, and characteristics of any seizure activity.
- One of the potential complications of a seizure is aspiration, which is the inhalation of foreign material into the lungs, such as saliva, vomit, or food. Aspiration can cause choking, pneumonia, or respiratory distress. To prevent or treat aspiration, the practical nurse (PN) should ensure the ready availability of equipment to perform suctioning of the trachea, which is the tube that connects the mouth and nose to the lungs. Suctioning of the trachea involves inserting a catheter through the nose or mouth into the trachea and applying negative pressure to remove any secretions or debris from the airway.
- Therefore, option A is the correct answer, while options B, C, and D are incorrect.
Option B is incorrect because inserting a urinary catheter is not related to seizure precautions or aspiration prevention.
Option C is incorrect because applying soft restraints may not be necessary or appropriate for a client who requires seizure precautions, as they may interfere with the natural movements of the seizure or cause injury to the client.
Option D is incorrect because inserting a nasogastric tube is not related to seizure precautions or aspiration prevention.
Correct Answer is D
Explanation
A. Initiate droplet isolation precautions is incorrect because cystic fibrosis is not transmitted by droplets, but by autosomal recessive inheritance.
B. Keep the child on NPO status for 12 hr is incorrect because there is no indication for withholding oral intake in this child. The child needs adequate hydration and nutrition to prevent dehydration and malnutrition due to increased metabolic demands and mucus production.
C. Maintain the child on bed rest for 24 hr is incorrect because bed rest can worsen the child's respiratory status by decreasing lung expansion and increasing mucus retention. The child needs to be encouraged to ambulate and participate in activities as tolerated to promote airway clearance and prevent atelectasis and infection.
D. Administer high-dose antibiotic therapy is correct because the child has signs of a pulmonary infection, such as wheezing, productive cough, and thick sputum. Antibiotics are indicated to treat the infection and prevent complications such as pneumonia and bronchiectasis.
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