A nurse is assisting with the care of a client.
The vital signs indicate abnormalities.
Which of the following actions should the nurse take?

Administer IV fluids as prescribed.

Place the client in a supine position.

Monitor for signs of infection.

Notify the provider about abnormal findings.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Administering IV fluids as prescribed can be essential for maintaining fluid balance, but it does not directly address abnormal vital signs unless they are linked to hypovolemia. The nurse should prioritize identifying the cause of the abnormalities first, and then proceed with interventions aimed at stabilization and correction.

Choice B rationale

Placing the client in a supine position can exacerbate certain conditions, such as respiratory distress or hypoxia. While position changes may be needed in specific cases, this is not a primary action for addressing abnormal vital signs unless positional changes are directly implicated.

Choice C rationale

Monitoring for signs of infection is an important ongoing care strategy, especially when abnormal findings suggest potential sepsis. However, it alone does not resolve immediate concerns with abnormal vital signs and must be paired with communication and treatment strategies.

Choice D rationale

Promptly notifying the provider about abnormal findings ensures that the client's condition is evaluated comprehensively. Providers can order additional assessments or interventions to address potential underlying issues, thereby preventing clinical deterioration.

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Correct Answer is A

Explanation

Choice A rationale

Inspiratory stridor reflects airway obstruction, potentially life-threatening following bronchoscopy. Causes include vocal cord edema or laryngospasm. Prompt intervention ensures airway patency and oxygenation. Audible stridor indicates urgent escalation.

Choice B rationale

Sore throat is anticipated due to irritation from the bronchoscope. This resolves without treatment, differentiating it from alarming symptoms like respiratory difficulty.

Choice C rationale

Post-bronchoscopy fever is common due to airway manipulation. Low-grade fever under 38.6°C does not necessitate urgent evaluation unless persistent or accompanied by other symptoms.

Choice D rationale

Bloody sputum results from mucosal trauma during the procedure. Minimal streaking is benign and resolves spontaneously. It does not indicate complications. .

A. Assist the client to ambulate to promote bowel movement. B. Encourage oral intake to prevent dehydration. C. Administer prescribed anti-emetics. D. Notify the provider for further evaluation.

Correct Answer is D

Explanation

Choice A rationale

Ambulation can stimulate peristalsis and promote bowel movements. However, ambulation is not the priority when the client reports severe abdominal pain rated 7/10 and vomiting. These symptoms could indicate a potential obstruction or other complications, and further evaluation is essential before initiating physical activity to avoid exacerbating the condition.

Choice B rationale

Encouraging oral intake is important to prevent dehydration, particularly if the client has been vomiting. However, this is not the first intervention, as assessing the underlying cause of the symptoms takes precedence. Increasing oral intake without addressing potential gastrointestinal obstruction may worsen the client's condition.

Choice C rationale

Administering antiemetics can provide symptom relief for nausea and vomiting. However, this intervention addresses a symptom rather than identifying the underlying cause of the client's abdominal pain and vomiting. Further evaluation by a provider is necessary before symptomatic management.

Choice D rationale

Notifying the provider allows for further evaluation and timely diagnosis of the cause of the abdominal pain and vomiting, which could indicate serious conditions like bowel obstruction or ischemia. Prompt medical evaluation is essential to determine the appropriate intervention and ensure the client's safety.

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A nurse is assisting with the care of a client.The vital signs indicate abnormalities.Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who had a bronchoscopy 12 hours ago.Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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A nurse is assisting with the care of a client.
The vital signs indicate abnormalities.
Which of the following actions should the nurse take?