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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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A is incorrect because it is an example of self-disclosure, not altruism. Self-disclosure is sharing personal information or feelings with others.

B is incorrect because it is an example of jealousy, not altruism. Jealousy is feeling threatened or resentful by someone else's success or happiness.

C is correct because it is an example of altruism, which is helping others without expecting anything in return. Altruism can enhance self-esteem and coping skills for clients who have breast cancer.

D is incorrect because it is an example of trust, not altruism. Trust is believing that someone is reliable and honest.

A. "I will administer aspirin to my child to treat pain or fever." B. "I will record an average of three readings from my child's peak expiratory flow meter." C. I will place carpet in my child's bedroom to control allergens." D. "I will make sure my child receives a yearly influenza immunization."

Correct Answer is D

Explanation

A. Incorrect. Aspirin can trigger asthma attacks in some children and should be avoided.

B. Incorrect. The peak expiratory flow meter should be used daily, not just when the child has symptoms, and the highest reading should be recorded, not the average.

C. Incorrect. Carpet can harbor dust mites, mold, and other allergens that can worsen asthma. It is better to have hardwood or tile floors and washable rugs.

D. Correct. Influenza immunization can prevent serious complications from respiratory infections in children with asthma.

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A nurse is conducting group therapy with clients who have breast cancer. The nurse should recognize which of the following statements by a client as an example of altruism?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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