A nurse is reviewing the medical record of a client. These are the medical reports; Hypoactive bowel sounds upon auscultation, abdomen soft, not distended on palpation and urinary output of 130mL/4hr. Which of the following findings should the nurse report to the provider?
Urine specific gravity
Prealbumin
Temperature
Bowel sounds
The Correct Answer is D
Choice A reason:
Urine specific gravity should not be reported by the nurse. While urine specific gravity is an important indicator of hydration status and kidney function, the provided information does not suggest any abnormalities in urinary output or signs of kidney issues. It is not the most critical finding to report in this scenario.
Choice B reason:
Prealbumin should not be reported by the nurse. Prealbumin is a protein used to assess nutritional status, but its significance in this situation is not apparent from the provided data. It may be relevant in other contexts, such as assessing malnutrition, but it does not directly address the current findings.
Choice C reason:
Temperature should not be reported by the nurse. The provided information does not include any data about the client's temperature, and there are no signs of infection mentioned. While temperature is an important vital sign, it is not relevant to the findings presented in this scenario.
Choice D reason
The nurse should report the "hypoactive bowel sounds upon auscultation" to the provider. Hypoactive bowel sounds can be a sign of gastrointestinal (GI) motility issues, which may indicate a potential problem with the client's digestive system. It could be due to various causes such as bowel obstruction, inflammation, or other GI disorders. Reporting this finding to the provider is essential so that appropriate assessments and interventions can be taken to address the client's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This client is at risk of harming themselves by removing the IV line, which could cause bleeding, infection, or loss of medication. This is a priority issue that requires immediate intervention by the nurse.
B. This client is experiencing a common side effect of pain medication, which can be managed by administering antiemetics, fluids, or changing the medication. This is not a life-threatening issue and can be addressed after attending to the client in choice A.
C. This client has a chronic condition that requires regular dialysis, but they are not in acute distress at this time. They should be monitored for signs of fluid overload, electrolyte imbalance, or infection, but they are not a priority over the client in choice A.
D. This client has a psychosocial need that should be respected and supported by the nurse, but it is not an urgent issue that requires immediate attention. The nurse can arrange for a visit from the chaplain after attending to the client in choice A.
Correct Answer is ["A","C","D"]
Explanation
A. Remove indwelling urinary catheter when no longer indicated: This action prevents urinary tract infections and promotes bladder function.
B. Elevate affected limb at chest level: This action is contraindicated because it increases venous pressure and edema in the affected extremity, which could compromise blood flow and nerve function.
C. Assist the adolescent with ambulation from bed to chair: This action prevents complications such as deep vein thrombosis, pulmonary embolism, pneumonia, and constipation by enhancing circulation, respiration, and bowel motility.
D. Perform neurovascular assessments every hour: This action monitors for signs of impaired blood flow or nerve function in the affected extremity, such as changes in color, temperature, sensation, movement, or pulse.
E. Apply warm packs to right extremity for the first 24hrs: This action is contraindicated because it increases blood flow and edema in the affected extremity, which could compromise blood flow and nerve function.
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