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 ["A","D"]
Explanation
Temperature 39.1° C (102.4° F),Temperature 39.2° C (102.5° F)
Correct Answer is A
Explanation
Choice A reason:
Plain yogurt is appropriate for a full-liquid diet as it is a liquid at room temperature and provides nutritional value.
A full-liquid diet consists of foods that are liquid at room temperature and can be easily poured or sipped. It includes clear liquids as well as liquids that are more opaque, like milk-based products and certain blended foods. Among the options provided:
Choice B reason:
Scrambled eggs are not appropriate. Scrambled eggs are not typically considered a part of a full-liquid diet. They have a solid texture and may not be suitable for this specific dietary progression.
Choice C reason:
Oatmeal is inappropriate. Oatmeal is a solid food that does not meet the criteria for a full-liquid diet. It is usually allowed on a soft or regular diet after appropriate postoperative recovery.
Choice D reason:
Applesauce is inappropriate. While applesauce is softer than solid foods, it is not typically included in a full liquid diet. It is more commonly associated with a soft or pureed diet.
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