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A nurse is caring for a male client in the emergency department.

Exhibits

The nurse is reviewing the clients electronic medical records
Select the 4 findings that require immediate follow-up.

Upper arm and lower leg findings

Skin temperature

Blood pressure

Bowel sounds

Hgb

Heart rate

Answer and Explanation

Correct Answer : A,C,E,F

Rationale:

A. Upper arm and lower leg findings: The presence of ecchymoses indicates impaired coagulation, which is common in chronic liver disease due to decreased clotting factor production. In the context of active bleeding (hematemesis), this is significant and needs immediate evaluation.

B. Skin temperature: Cool and dry skin, while concerning, is a nonspecific symptom. It may support a diagnosis of hypovolemia or shock, but on its own, it does not require the same urgent intervention as abnormal vital signs or lab results.

C. Blood pressure: A BP of 92/56 mm Hg indicates hypotension and suggests the client may be experiencing hypovolemic shock from gastrointestinal bleeding. This finding requires immediate intervention to prevent end-organ damage.

D. Bowel sounds: Bowel sounds auscultated in all four quadrants suggest that gastrointestinal motility is present. This is not a priority finding and does not indicate an urgent complication.

E. Hgb: A hemoglobin level of 7 g/dL is critically low and consistent with significant blood loss. This value requires immediate follow-up, likely including blood transfusion and identification of the bleeding source.

F. Heart rate: A heart rate of 118/min reflects a compensatory response to hypotension or blood loss. Tachycardia in this setting is a key sign of circulatory compromise and must be addressed immediately.

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Correct Answer is B

Explanation

Rationale:
A. The stool will have a tarry color: Tarry stools typically indicate the presence of digested blood from upper gastrointestinal bleeding. This is not expected after an ileostomy, which involves the small intestine, not the upper GI tract.

B. The stool will have a high volume of liquid: After a colectomy with ileostomy placement, stool bypasses the colon, where most water reabsorption occurs. As a result, the output from an ileostomy is typically frequent and liquid or semi-liquid in consistency.

C. The stool will be solid and well-formed: Solid, well-formed stools are characteristic of a functioning colon. Because the colon is removed in a colectomy with ileostomy, stool will not be solid due to the lack of water absorption.

D. The stool will appear bloody with clots: Bloody stools with clots suggest active bleeding, which is not expected in normal postoperative ileostomy output. This would be an abnormal finding and should be reported immediately.

A. Peripheral pulse B. Pain level C. Blood pressure D. Appearance of the dressing site E. Heart rate F. Temperature G. Abdominal assessment H. Oxygen saturation

Correct Answer is ["A","B","C","E","H"]

Explanation

Rationale:

Peripheral pulse: Strong and symmetric peripheral pulses in this client indicate that circulation through the femoral artery (the common catheter insertion site for PCI) is intact. This suggests no vascular complications like thrombus or hematoma, which are post-PCI risks.
Pain level: The client initially reported chest pain rated 8/10 with radiation to the left arm and dyspnea. A decreased pain level after PCI reflects reduced myocardial oxygen demand and ischemia, indicating that the intervention was successful.
Blood pressure: The client presented with elevated blood pressure (158/92 mm Hg), likely due to cardiac stress and pain. A return to a more stable range post-intervention indicates reduced sympathetic activation and improved hemodynamic status.
Heart rate: The client had a heart rate of 116/min earlier, likely secondary to chest pain and cardiac stress. A drop toward normal levels post-PCI reflects improved cardiac function and relief of ischemia.
Oxygen saturation: Earlier, the client showed dyspnea and shallow, labored respirations, with an SpO₂ of 96% on room air. An improved or sustained oxygen saturation level after PCI indicates better oxygen delivery and respiratory status, confirming reduced cardiac workload and improved perfusion.

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A nurse is caring for a male client in the emergency department. Exhibits The nurse is reviewing the clients electronic medical records Select the 4 findings that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing preoperative teaching about stool consistency to a client who will undergo a colectomy with the placement of an ileostomy. Which of the following information about stool consistency should the nurse include in the teaching?

Correct Answer is B

Explanation

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Correct Answer is ["A","B","C","E","H"]

Explanation

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A nurse is caring for a male client in the emergency department.

Exhibits

The nurse is reviewing the clients electronic medical records
Select the 4 findings that require immediate follow-up.