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A nurse on a medical surgical unit is admitting a client from a provider's office.

Exhibits
Click to highlight the information in the Nurse's Notes and Vital Signs that should be reported to the provider.

1500:                         

  • Temperature: 39 degrees Celcius (102.2 F)
  • Heart rate: 122/min
  • Respiratory rate: 24/min
  • BP: 106/54 mmHg
  • Oxygen saturation: 95% on room air

1530:

  • Client lethargic, reporting abdominal cramping, experiencing projectile vomiting.
  • Voiding dark, concentrated urine.
  • Client requesting water

A.

Temperature: 39 degrees Celcius (102.2 F)

B.

Heart rate: 122/min

C.

Respiratory rate: 24/min

D.

BP: 106/54 mmHg

E.

Oxygen saturation: 95% on room air

F.

Client lethargic, reporting abdominal cramping, experiencing projectile vomiting.

G.

Voiding dark, concentrated urine.

H.

Client requesting water

Answer and Explanation

The Correct Answer is ["A","B","D","F","G","H"]

Vital Signs

  • Temperature: 39°C (102.2°F) → fever worsened since admission (sign of possible infection).
     
  • Heart rate: 122/min → tachycardia, worsened compared to earlier.
     
  • Blood pressure: 106/54 mmHg → trending downward, may indicate fluid deficit/hypotension risk.

Nurse’s Notes

  • Client lethargic → worsening mental status.
     
  • Projectile vomiting → new onset, risk of dehydration and electrolyte imbalance.
     
  • Abdominal cramping → possible gastrointestinal complication.
     
  • Voiding dark, concentrated urine → sign of dehydration.
     
  • Client requesting water → excessive thirst consistent with hyperglycemia/possible hyperosmolar state.


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Related Questions

Correct Answer is B

Explanation

Rationale:
A. The color change of stool is not the purpose of the laxative.
B. A laxative is necessary to help eliminate barium from the gastrointestinal tract, preventing constipation or impaction.
C. The laxative is not used to prevent magnesium absorption; this is unrelated to a barium study.
D. While facilities have protocols, the explanation should focus on patient safety and the purpose of the intervention, not just policy.

Correct Answer is B

Explanation

Rationale:
A. Lactulose is usually administered orally to soften stools, not as a short-retention enema.
B. A Fleet enema is a hypertonic solution that draws fluid into the colon, is retained briefly, and promotes rapid evacuation of stool to relieve constipation.
C. Tap water enemas are hypotonic and typically require immediate expulsion, not short retention.
D. Mineral oil enemas are retention enemas, meant to soften stool over a longer period, not for rapid evacuation.

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