A nurse is caring for a client who had an open cholecystectomy 24 hours ago.
The client’s vital signs have been stable over the last 24 hours, with the most recent temperature
98.6° F(37° C), blood pressure (BP) 118/76 mm Hg, respiratory rate (RR) 16/min, and pulse 78/min, but are now changing.
Which set of vital signs indicates that the nurse should contact the health care provider?
temperature 97.5° F(36.4° C), BP 98/64 mm Hg, pulse 90/min, RR 18/min.
temperature 99.5° F (37.5° C), BP 126/80 mm Hg, pulse 68/min, RR 16/min.
temperature 100.7° F (38.2° C), BP 118/68 mm Hg, pulse 84/min, RR 20/min.
temperature 101.8° F(38.8° C), BP 100/60 mm Hg, pulse 98/min, RR 28/min.
The Correct Answer is D
temperature 101.8° F(38.8° C), BP 100/60 mm Hg, pulse 98/min, RR 28/min. This set of vital signs indicates that the client may have an infection or sepsis, which are potential complications of an open cholecystectomy. The client has a fever, tachycardia, tachypnea, and hypotension, which are signs of systemic inflammatory response syndrome (SIRS).
Choice A is wrong because it shows mild hypothermia, hypotension, and tachycardia, which could be due to dehydration or blood loss, but not necessarily infection.
Choice B is wrong because it shows a slight fever, normal blood pressure, and bradycardia, which could be due to pain or medication, but not infection.
Choice C is wrong because it shows a low-grade fever, normal blood pressure and pulse, and mild tachypnea, which could be due to inflammation or dehydration, but not infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The nurse should complete an incident report when he or she contaminates and discards two indwelling catheters during the insertion procedure. This is because an incident report is a tool for documenting any event that is not consistent with the routine operation of a health care unit or the routine care of a client. An incident report helps to identify potential risks and improve quality and safety.
Choice A is wrong because not completing the care plan for a newly admitted client before leaving the unit is not an incident that requires reporting.
It is a matter of time management and prioritization.
Choice B is wrong because recording a client’s refusal to take prescribed medication on the chart is not an incident that requires reporting.
It is a part of the nursing documentation and communication.
Choice D is wrong because experiencing back pain after moving a client up in the bed is not an incident that requires reporting.
It is a personal injury that may be related to improper body mechanics or ergonomics.
Correct Answer is B
Explanation
Limiting fluid intake can lead to dehydration and concentrated urine, which can irritate the bladder and increase the risk of infection. Older adults should drink about 2 liters of fluid per day unless they have a medical condition that requires fluid restriction.
Choice A is correct because taking diuretics in the morning can reduce nocturia and improve sleep quality.
Choice C is correct because using a commode next to the bed can prevent falls and injuries that may occur when trying to reach the bathroom in a hurry.
Choice D is correct because using a commode in the room can preserve dignity and comfort, and reduce skin breakdown and odor that may result from wearing adult briefs.
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