The client is a 12-year-old male who sustained a gunshot wound to his abdomen. He had a surgical repair of a perforated small intestine 4 days ago. The client is 112.4 Ib. (51 kg). He has a nasogastric tube, a left femoral central line for fluids, and a right hand peripheral intravenous line.
Review H and P, laboratory results, flow sheet, and orders.
The nurse receives the report from the lab and documents the intake and output for 1600.
Based on the client's information at 1600, what symptoms should the nurse look for? Select all that apply.
Edema
Irritability
Fatigue
Dry skin
Intense thirst
Muscle weakness
Hypertension
Correct Answer : A,D,E,F
A. Edema can be a symptom to watch for, as it may indicate fluid retention or imbalance, especially in a client who has received intravenous fluids.
D. Dry skin may be a symptom to observe, as it could suggest dehydration or fluid imbalances.
E. Intense thirst is a symptom to be alert for, as it may be an indication of dehydration or an electrolyte imbalance.
F. Muscle weakness is a potential symptom to monitor for, as it could be related to electrolyte imbalances or other complications following surgery and injury.
B, C, and G are not the primary symptoms to expect based on the client's information and history, but they should still be monitored as part of routine assessment. Irritability and fatigue can be nonspecific symptoms that may occur in various clinical situations. Hypertension may or may not be a symptom, and it is essential to assess the client's blood pressure in the context of their overall condition.
The client's history and the presence of medical devices and surgical intervention indicate the need for close monitoring of fluid balance and electrolyte status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Documenting the client's relief of pain is important for the medical record but is not the first priority in this situation. The immediate concern is to determine the cause of the sudden pain relief and ensure the child's well-being.
B. Inquiring about the client's last meal is important for pre-operative considerations, but it is not the first action to take when sudden relief of abdominal pain is reported.
C. Giving prescribed intravenous antibiotics may be part of the treatment plan, but it should not be the first action when the child experiences sudden relief of abdominal pain. Contacting the healthcare provider to assess the situation is more urgent.
D Contact the healthcare provider.
In the case of a child diagnosed with appendicitis, sudden relief in abdominal pain can be concerning. This might indicate that the appendix has ruptured, leading to the spread of infection into the abdominal cavity, which can be a critical situation. It's essential for the healthcare provider to be informed immediately so they can assess the child's condition, order any necessary interventions, and potentially expedite the surgical procedure if required.
Correct Answer is C
Explanation
A. Ensure placement of the enteral tube with an abdominal x-ray:Verifying enteral tube placement is essential for safety, but it is not related to maintaining the newborn's growth and development. Tube placement should already have been verified prior to initiating feedings.
B. Speak to the healthcare provider about instituting physical therapy:Physical therapy may be beneficial for infants with specific motor delays, but it is not a routine intervention for all infants recovering from gastroschisis.
C. Offer a pacifier for non-nutritive sucking:Non-nutritive sucking (e.g., using a pacifier) is crucial for the growth and development of newborns, especially those unable to feed orally. It helps promote oral-motor development, soothes the infant, and lays the foundation for transitioning to oral feeding. This is particularly important for an infant receiving parenteral or enteral nutrition to ensure they develop the skills and comfort needed for future oral feeding.
D. Use sterile technique during feedings:Clean technique is generally sufficientor routine enteral feedings unless there is a specific indication for sterility (e.g., immunocompromised clients). Further, this does not directly support growth and development.
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