The nurse is obtaining vital sign measurements every 15 minutes for a client who had an emergency appendectomy and currently has a temperature of 101.4°F (38.6°C). Which vital sign measurements should the nurse report to the healthcare provider?

Heart rate 80 beats/minute, respirations 18 breaths/minute, and blood pressure 140/70 mmHg.

Heart rate 110 beats/minute, respirations 22 breaths/minute, and blood pressure 88/56 mmHg.

Heart rate 62 beats/minute, respirations 19 breaths/minute, and blood pressure 150/90 mmHg.

Heart rate 100 beats/minute, respirations 24 breaths/minute, and blood pressure 118/68 mmHg.

Answer and Explanation

The Correct Answer is B

Choice A reason: These vital signs are within normal limits and do not indicate an immediate concern that requires reporting to the healthcare provider.

Choice B reason: This set of vital signs shows a heart rate of 110 beats/minute, which is tachycardia, and a blood pressure of 88/56 mmHg, which is hypotension. Both of these findings, combined with the client's fever, could indicate sepsis or other complications that require immediate attention.

Choice C reason: These vital signs are relatively stable and do not indicate a critical issue that requires immediate reporting.

Choice D reason: While these vital signs show an elevated respiratory rate, they are not as critical as the vital signs in Choice B, which show hypotension and tachycardia.

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Correct Answer is D

Explanation

Choice A reason: Serum potassium of 5.0 me/L and serum sodium of 138 me/L are within normal ranges and do not reflect the expected electrolyte imbalances due to dehydration from vomiting and diarrhea.

Choice B reason: Serum potassium of 4.5 me/L and serum sodium of 140 me/L are also within normal ranges. This does not reflect the typical imbalance caused by dehydration.

Choice C reason: Serum potassium of 3.5 me/L and serum sodium of 142 me/L are normal values. They do not indicate the electrolyte disturbances expected with dehydration from vomiting and diarrhea.

Choice D reason: Serum potassium of 3.0 me/L indicates hypokalaemia (low potassium), and serum sodium of 149 me/L indicates hypernatremia (high sodium). These imbalances are expected in a client with a history of fever, vomiting, and diarrhea, as these conditions can lead to loss of potassium and concentration of sodium due to dehydration.

A. "You will feel drowsy for several hours after surgery." B. "You will need to get out of bed the day after surgery." C. "Your clear liquid diet will include gelatine and tea." D. "Your bowel sounds will be assessed every four hours."

Correct Answer is B

Explanation

Choice A reason: Informing the client that they will feel drowsy for several hours after surgery is important for setting realistic expectations about the immediate postoperative period. However, it is not the most critical information to ensure adherence to the postoperative regimen.

Choice B reason: It is essential to inform the client about the importance of early mobilization, which involves getting out of bed the day after surgery. Early mobilization helps prevent complications such as deep vein thrombosis (DVT), pulmonary embolism, and pneumonia. Emphasizing this information preoperatively ensures that the client understands the necessity of moving and participating in their recovery process, which is vital for successful postoperative outcomes.

Choice C reason: Explaining the components of a clear liquid diet, including gelatine and tea, is helpful for the client to know what to expect in terms of dietary modifications. However, it is not as critical as informing the client about early mobilization, which has a direct impact on their recovery and prevention of complications.

Choice D reason: Informing the client that their bowel sounds will be assessed every four hours is part of routine postoperative care. While it is important for the client to understand the monitoring process, it is not the most crucial aspect to ensure adherence to the postoperative regimen. Early mobilization has a more significant impact on the client’s overall recovery.

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The nurse is obtaining vital sign measurements every 15 minutes for a client who had an emergency appendectomy and currently has a temperature of 101.4°F (38.6°C). Which vital sign measurements should the nurse report to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client reports a 2-day history of fever, vomiting, and diarrhea. The healthcare provider prescribes serum electrolyte levels to be obtained. Which laboratory results should the nurse expect?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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