A nurse is collecting data from a client who is 12 hr postoperative following intestinal surgery. Which of the following findings should the nurse report to the charge nurse prior to client ambulation?

Oxygen saturation 90%

Respiratory rate 20/min

Apical pulse rate 88/min

Oral temperature 37.6° C (99.7° F)

Answer and Explanation

The Correct Answer is A

An oxygen saturation level of 90% is below the normal range and indicates inadequate oxygenation. This finding could indicate respiratory compromise or impaired lung function, which may require further assessment and intervention before allowing the client to ambulate.

The respiratory rate of 20 breaths per minute, apical pulse rate of 88 beats per minute, and oral temperature of 37.6°C (99.7°F) are within the expected range and do not raise immediate concerns that require reporting to the charge nurse prior to ambulation.

However, the nurse should continue to monitor these vital signs during and after ambulation to ensure stability.

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Correct Answer is B

Explanation

Stomatitis is an inflammation of the oral mucosa, which can cause pain, discomfort, and difficulty eating. To manage stomatitis, clients should consume soft, bland foods that are easy to chew and swallow, such as cooked vegetables, mashed potatoes, and oatmeal.

Acidic, spicy, or crunchy foods should be avoided. Using lemon glycerin swabs can irritate the oral mucosa, so they should not be used.

Mouthwashes containing alcohol can cause further irritation, so they should also be avoided. Eating foods high in vitamin B12 can be helpful for preventing stomatitis, but it is not an appropriate intervention for managing an existing case of stomatitis.

A. Use hydrogen peroxide for wound cleaning. B. Perform dressing changes every other day. C. Cleanse the most contaminated wounds first, D. Apply dressings with sterile gloves.

Correct Answer is D

Explanation

A.Using hydrogen peroxide for wound cleaning is not recommended as it can cause tissue damage and delay healing.

B.Burn dressings should typically be changed more frequently, often at least once per day, depending on the type and severity of the burn and the type of dressing used.Delaying dressing changes could increase the risk of infection.
C.In wound care, the nurse should cleanse the least contaminated wounds first to prevent spreading microorganisms from more contaminated areas to cleaner areas. This reduces the risk of cross-contamination and infection. For burns, starting with the cleanest areas ensures a safer wound management process.

D.Applying dressings with sterile gloves is essential to maintain a sterile environment and reduce the risk of infection, especially in clients with burns who are at high risk for infection due to compromised skin integrity.

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A nurse is collecting data from a client who is 12 hr postoperative following intestinal surgery. Which of the following findings should the nurse report to the charge nurse prior to client ambulation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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