Patient Data
The nurse is reviewing the client's initial assessment findings.
Which assessment findings require follow-up? Select all that apply.
IV site without redness or swelling
Temperature: 98.8° F (37.1° C)
Respirations: 28 breaths/minute
Heart rate: 92 beats/minute
Taking shallow breaths
Alert and oriented to person, place, time and situation
Pain 8 on a 0 to 10 scale
Blood pressure: 138/82 mm Hg
Blood pressure: 138/82 mm Hg
Correct Answer : C,E,G
A. IV site without redness or swelling: The IV site appears normal with no signs of infiltration or infection, so no immediate follow-up is required. This finding indicates proper IV insertion and maintenance.
B. Temperature: 98.8° F (37.1° C): This is within normal limits and does not indicate fever or infection, so it does not require immediate follow-up.
C. Respirations: 28 breaths/minute: This is above the normal adult range (12–20 breaths/minute) and may indicate respiratory distress due to pain, shallow breathing, or possible pulmonary complications such as atelectasis or pneumonia, requiring close monitoring and follow-up.
D. Heart rate: 92 beats/minute: Slightly elevated but within mild tachycardia range, which could be related to pain or anxiety. It should be monitored but does not require urgent follow-up.
E. Taking shallow breaths: Shallow breathing is concerning in a client with rib fractures, as it increases the risk for hypoventilation, atelectasis, and pneumonia. This requires immediate intervention, such as pain management and respiratory support.
F. Alert and oriented to person, place, time, and situation: Cognitive status is normal, so no follow-up is needed.
G. Pain 8 on a 0 to 10 scale: Severe pain limits deep breathing and mobility, increasing the risk of complications. Pain management should be addressed promptly to improve comfort and respiratory function.
H. Blood pressure: 138/82 mm Hg: Slightly elevated, likely related to pain or stress. Monitor trends, but it does not require immediate follow-up at this time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"C"}}
Explanation
• Temperature 98.1°F (36.7°C): Afebrile status indicates that the body is not mounting a febrile response to pathogens, showing infection is being prevented postoperatively.
• pH 7.40: Normal pH reflects adequate perfusion and circulation after fluid resuscitation, suggesting hypovolemia has been managed effectively.
• Blood pressure 112/77 mm Hg: Stable blood pressure within normal range after fluid bolus demonstrates restoration of circulating volume, consistent with hypovolemia management.
• Capillary refill 2 seconds: Normal refill indicates improved tissue perfusion after fluid therapy, confirming adequate correction of hypovolemia.
• Pain 0 on a scale of 0 to 10: Absence of reported pain while sedated indicates comfort and relief of anxiety, showing pain control is being achieved.
• Surgical dressing dry and intact: A clean, dry surgical site without drainage supports the goal of preventing infection after abdominal trauma surgery.
• PaCO2 42 mm Hg: PaCO 2 of 42mmHg is within the normal range (35−45mmHg) and indicates effective ventilation. This is primarily an ABC or respiratory goal, not directly related to the three listed goals.
Correct Answer is A
Explanation
A. Sugar cookies: Sugar cookies are low in fat and not highly acidic, making them less likely to trigger reflux. This choice demonstrates understanding of dietary restrictions because it avoids common GERD triggers such as high-fat, spicy, or acidic foods.
B. Pizza: Pizza is high in fat, contains tomato sauce, and often includes spices—all of which can increase gastric acid secretion and exacerbate reflux symptoms. This food is not an appropriate choice for a child with GERD.
C. Tacos: Tacos typically contain seasoned meat, spices, and fatty ingredients that are known to aggravate reflux. The combination of fat and spice makes them unsuitable for someone managing GERD symptoms.
D. Chocolate milkshake: Chocolate and high-fat dairy products can lower esophageal sphincter tone and delay gastric emptying, both of which contribute to worsening reflux. This makes it an inappropriate snack option.
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