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)
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
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Numbness of the toes in a client with a femur fracture may indicate neurovascular compromise, which requires immediate attention.
It could be a sign of impaired circulation or nerve damage, and prompt assessment is needed to prevent further complications or permanent damage.
Correct Answer is A
Explanation
A nurse is assisting with the care of a client who has hearing loss and has questions regarding their medication. The nurse should choose a room that is well-lit, sit facing the client, speak clearly and slowly, and ask a few questions at a time. Exaggerating lip movement while speaking is not recommended as it can be difficult for the client to read lips accurately. Additionally, sitting on the client's right side may not make a significant difference in their ability to hear.
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