The practical nurse (PN) is providing care for a client who is ordered nothing by mouth (NPO) after a small bowel resection. The client's nasogastric (NG) tube is connected to low intermitent suction. The client reports dizziness and tingling in digits.
Which assessment finding by the PN should be reported to the healthcare provider?
Hyperactive bowel sounds on assessment.
Heart rate of 90 beats per minute with premature ventricular contractions (PVCs) noted on telemetry.
Hypoactive bowel sounds on assessment
Regular heart rate of 100 beats per minute on telemetry
The Correct Answer is B
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is the best action for the PN to implement because it addresses the client's question and provides an opportunity to educate the client about fecal diversion surgery and its outcomes. The PN should review the type, location, and appearance of the surgical opening (stoma) and explain how it will affect the client's elimination and body image.
B. Verifying that the client had nothing by mouth (NPO) for the past 24 hours is not relevant to the client's question and does not provide any information or support.
C. Asking the client if he finished the bowel sterilization prescription is not relevant to the client's question and does not provide any information or support.
D. Determining if this is the first indwelling catheter the client has had is not relevant to the client's question and does not provide any information or support.
Correct Answer is C
Explanation
The correct answer is choice C - IV infusion site is infiltrated. Choice A rationale:
The client reports feeling nauseous. While this symptom should be monitored, it is not the most crucial finding to report for a client in Addison's crisis. Nausea can be a common symptom during various medical conditions and may not warrant immediate action.
Choice B rationale:
Has not voided in four hours. While monitoring urine output is important, it may not be the most critical finding in Addison's crisis. Other symptoms like electrolyte imbalances and
circulatory collapse is more concerning in this scenario.
Choice C rationale:
IV infusion site is infiltrated. In Addison's crisis, the client's condition may be precarious, and any complications with IV therapy could worsen the situation. It is essential to report this finding promptly to prevent further complications.
Choice D rationale:
A serum glucose level of 85 mg/dL. While monitoring glucose levels is essential in many situations, a glucose level of 85 mg/dL is within the reference range, which means it is not the most critical finding in Addison's crisis.
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