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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Hyperactive bowel sounds are bowel sounds that are louder and more frequent than normal. They may be heard as high-pitched rushing or tinkling sounds that occur irregularly at a rate greater than 5-6 sounds per minute. They are often associated with increased intestinal motility, such as diarrhea, gastroenteritis, or early bowel obstruction.
Option b is incorrect because hyperactive bowel sounds are not typically associated with a paralytic ileus, which is a condition where the bowel stops working and there is a lack of bowel sounds.
Option c is incorrect because hyperactive bowel sounds indicate increased motility, not decreased motility.
Option d is incorrect because soft bowel sounds at a rate of 1/min are considered hypoactive bowel sounds, which can be a sign of decreased intestinal motility, as seen in constipation or postoperative ileus.
Correct Answer is B
Explanation
People with SLE are often sensitive to sunlight and should take precautions to protect their skin. Limiting time in the tanning bed is important because exposure to ultraviolet (UV) light can trigger or worsen symptoms of SLE. Using an astringent on the face and cleansing with an antibacterial soap may not be recommended for individuals with SLE, as these products can be harsh on the skin and may cause irritation. However, patting the skin dry with a towel is a gentle and appropriate method to dry the skin without causing unnecessary friction or irritation.
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