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: Drinking regular colas can lead to fluctuations in blood glucose levels and is not an appropriate recommendation for managing nausea in a client with diabetes.

Choice B reason: Not injecting additional insulin until solid food can be tolerated is not advisable, as it may lead to hyperglycaemia or diabetic ketoacidosis. Insulin needs to be managed carefully even if the client is not eating.

Choice C reason: Going to the emergency room immediately may not be necessary if the client can manage their blood glucose levels at home with proper guidance.

Choice D reason: Monitoring blood glucose levels and drinking fluids as tolerated is the best initial advice. This helps prevent dehydration and maintain glucose control while dealing with the nausea. The client should also follow sick day management guidelines for diabetes and stay in touch with their healthcare provider.

A. Minimize intake of spicy foods. B. Begin a smoking cessation program. C. Avoid wearing tight-fitting clothes. D. Remain upright following meals.

Correct Answer is D

Explanation

Choice A reason: Minimizing the intake of spicy foods can help reduce GERD symptoms, but it is not the most critical instruction for preventing reflux immediately after eating.

Choice B reason: Beginning a smoking cessation program is important for overall health and can help reduce GERD symptoms over time, but it is not the immediate priority for preventing reflux.

Choice C reason: Avoiding tight-fitting clothes can help reduce pressure on the abdomen and lessen reflux symptoms, but it is not the most urgent instruction to emphasize at discharge.

Choice D reason: Remaining upright following meals is crucial for preventing reflux. Lying down immediately after eating can cause stomach contents to flow back into the oesophagus, exacerbating GERD symptoms. This instruction is key to managing the condition effectively.

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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

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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