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A nurse on a medical-surgical unit is assisting in the care of a male client.
Exhibits
Which of the following findings indicate a need for follow-up by the nurse? Select all that apply.

Temperature

Heart rate

Skin findings

Respiratory rate

Oxygen saturation

Blood pressure

Urinary output

Answer and Explanation

Correct Answer : B,F,G

A. Temperature: The temperature remains stable and within normal limits. A postoperative temperature range of 36.3° C (97.3° F) to 36.4° C (97.5° F) is not indicative of infection or other complications at this time.

B. Heart rate: The heart rate has increased from 84/min to 104/min, indicating sinus tachycardia. This could be a compensatory response to decreased blood volume or another underlying issue, necessitating further assessment.

C. Skin findings: The skin findings are described as warm and dry, which is normal. No abnormalities are noted, so this does not require follow-up.

D. Respiratory rate: The respiratory rate has increased slightly to 24/min but is not significantly abnormal. This may not be a priority for follow-up unless other symptoms are present.

E. Oxygen saturation: The oxygen saturation is within normal limits (96% on room air), suggesting adequate oxygenation. No immediate concerns are evident based on this measurement.

F. Blood pressure: The blood pressure has dropped from 106/74 mm Hg to 88/54 mm Hg, indicating possible hypotension. This drop could signal hypovolemia or bleeding, requiring prompt follow-up to investigate the cause.

G. Urinary output: The urinary output of 110 mL over 6 hours is low, which might indicate dehydration or renal issues. Monitoring and addressing this finding are important to ensure adequate fluid balance and kidney function.

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Correct Answer is C

Explanation

A. The medication reduces the rate at which the kidneys filter waste: This is incorrect as oxybutynin does not affect kidney function or the rate at which kidneys filter waste.
B. The medication decreases the sensitivity of the urethral sphincter: This is incorrect because oxybutynin primarily affects bladder muscle contraction, not the sensitivity of the urethral sphincter.
C. The medication prevents the bladder muscles from involuntarily contracting: This is correct as oxybutynin is an anticholinergic medication that reduces involuntary bladder contractions, leading to less frequent urination.
D. The medication blocks the nervous system impulse to produce urine: This is incorrect because oxybutynin works by blocking the action of acetylcholine in the bladder, not by blocking impulses to produce urine.

A. Orthopnea B. Lower-extremity edema C. Clammy skin D. Pink, frothy sputum

Correct Answer is B

Explanation

A. Orthopnea: This is more commonly associated with left-sided heart failure, where fluid accumulation in the lungs causes difficulty breathing when lying flat.
B. Lower-extremity edema: This is correct as right-sided heart failure often leads to fluid retention in the body, resulting in swelling of the lower extremities.
C. Clammy skin: This is not a typical finding specific to right-sided heart failure and may be seen in other conditions or complications.
D. Pink, frothy sputum: This is characteristic of left-sided heart failure and pulmonary edema, not right-sided heart failure.

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A nurse on a medical-surgical unit is assisting in the care of a male client. Exhibits Which of the following findings indicate a need for follow-up by the nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is talking with a client who takes oxybutynin. The client asks why he does not urinate as often. Which of the following information should the nurse include about the action of oxybutynin?

Correct Answer is C

Explanation

A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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A nurse on a medical-surgical unit is assisting in the care of a male client.
Exhibits
Which of the following findings indicate a need for follow-up by the nurse? Select all that apply.