A nurse is caring for a client.
Click on the findings that require immediate follow-up. To deselect a finding, click on the finding again.
Nurses' Notes
1500:
Client is alert and oriented to person, place, and time. Client is 4 hr postoperative following abdominal surgery. Surgical site has a small amount of serosanguineous drainage on dressing. Dressing is intact. Client reports pain as 5 on a scale of 0 to 10. Lung sounds are diminished in posterior lobes. Bowel sounds are hypoactive in all 4 quadrants. Last bowel movement was this morning.
1730:
Client is restless and short of breath. Reports pain as 8 on a scale of 0 to 10. Pain medication administered.
Vital Signs
1730:
- Temperature 37.2° C (98.9° F)
- Blood pressure 168/84 mm Hg
- Heart rate 116/min
- Respiratory rate 24/min
- Oxygen saturation 93% on room air
a small amount of serosanguineous drainage
Lung sounds are diminished in posterior lobes
pain as 5 on a scale of 0 to 10
Blood pressure 168/84 mm Hg
Respiratory rate 24/min
Oxygen saturation 93% on room air
Bowel sounds are hypoactive in all 4 quadrants
The Correct Answer is ["A","B","C","D"]
a small amount of serosanguineous drainage,
Lung sounds are diminished in posterior lobes,
pain as 8 on a scale of 0 to 10,
Blood pressure 168/84 mm Hg
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
The cephalic vein on the back of the right hand is incorrect because it might still involve the same arm as the mastectomy site, and it is important to avoid this side.
Choice B reason:
The radial vein on the left wrist is incorrect because it is not on the opposite side of the mastectomy and could increase the risk of lymphedema.
Choice C reason:
The basilic vein in the right antecubital fossa is the appropriate answer. When inserting an IV catheter for a client who has undergone a right mastectomy, it is generally advisable to avoid the arm on the same side as the mastectomy due to the risk of lymphedema and impaired lymphatic drainage. The basilic vein in the right antecubital fossa (the inner bend of the right elbow) would be a suitable choice in this case, as it is on the opposite side of the mastectomy.
Choice D reason:
The cephalic vein in the left distal forearm is on the same side as the mastectomy and should be avoided to reduce the risk of complications.
Correct Answer is A
Explanation
Choice A reason:
Delirium is a sudden and acute change in mental status characterized by confusion, disorientation, altered consciousness, and other cognitive disturbances. It has an abrupt onset and is often related to an underlying medical condition, medication, or other factors such as infections or metabolic imbalances.
Choice B reason:
Delirium can indeed affect a client's sleep cycle. It often disrupts sleep patterns and can lead to sleep disturbances
Choice C reason:
Delirium does not have a slow progression. It is typically characterized by a rapid and fluctuating course, and it can develop over hours to days.
Choice D reason:
Delirium does affect a client's perception of their environment. Clients with delirium may experience hallucinations, paranoia, and other alterations in perception. They may be unable to accurately interpret or interact with their surroundings.
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