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:
Placing the wasted portion of the controlled substance in the sharp container is not correct. Wasted controlled substances should be disposed of according to specific regulations and facility protocols.
Choice B reason:
Asking a second nurse to record her signature when wasting an unused portion of the controlled substance is not a standard practice. The process for wasting controlled substances usually involves following specific documentation procedures, but this does not necessarily require a second nurse's signature.
Choice C reason:
Verifying the count total of the controlled substance after removing the amount needed is the appropriate action. When administering a controlled substance, it is crucial to maintain accurate accountability of the medication. This includes verifying the count total of the controlled substance before and after removing the amount needed for administration. This step helps ensure proper documentation, prevent errors, and maintain appropriate control over controlled substances.
Choice D reason:
Reporting any discrepancy in the count total of the controlled substance after administration is important, but it should be done as a separate step from verifying the count total before administration. Discrepancies should be reported according to facility policy to ensure proper investigation and resolution.
Correct Answer is ["A","B","C","E","F"]
Explanation
Client Symptoms:
- Urinary Symptoms: The client reports a 2-day history of urinary frequency, burning on urination, and both lower back and suprapubic pain.
- Fever: The client states they developed a fever this morning.
Urinalysis Results:
- Appearance: Cloudy urine.
- Leukocyte Esterase: Positive, indicating the presence of white blood cells.
- Nitrites: Present, suggesting bacterial infection.
Assessment:
- These findings strongly suggest a Urinary Tract Infection (UTI). The combination of urinary symptoms, fever, and urinalysis results supports this diagnosis.The nurse should promptly report these findings to the healthcare provider to ensure timely intervention.
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