During a two-week postoperative follow-up home visit, a client who had gastric bypass surgery exhibits abdominal tenderness, shoulder pain, and feelings of malaise.
The client’s vital signs are an oral temperature of 101.80F (38.8° C), a blood pressure of 100/50 mm Hg, a heart rate of 104 beats/minute, and a respiratory rate of 18 breaths/minute.
What is the appropriate action for the nurse to take?
Recheck the client’s vital signs in 30 minutes.
Have the client transported via ambulance to the hospital.
Determine the client’s current oxygen saturation rate.
Instruct the client to drive to the hospital for admission.
The Correct Answer is B
Answer and explanation
The correct answer is Choice B.
Choice A rationale
Rechecking the client’s vital signs in 30 minutes may not be the most appropriate action in this situation. The client is showing signs of possible complications such as infection (elevated
temperature, malaise) and referred pain in the shoulder, which could indicate diaphragmatic irritation. These symptoms, along with the client’s recent surgery, suggest that immediate medical attention may be necessary.
Choice B rationale
Having the client transported via ambulance to the hospital is the most appropriate action. The client’s symptoms suggest possible complications that require immediate medical attention.
Abdominal tenderness and shoulder pain could indicate a serious condition such as a perforation or infection. The elevated heart rate and low blood pressure could suggest sepsis or shock. Immediate medical evaluation and treatment are necessary.
Choice C rationale
Determining the client’s current oxygen saturation rate is important, but it is not the most immediate need. While this information could provide additional data about the client’s condition, it does not address the potential seriousness of the client’s symptoms. The client needs immediate medical attention.
Choice D rationale
Instructing the client to drive to the hospital for admission is not the best choice. Given the client’s symptoms and recent surgery, it would be safer for the client to be transported by ambulance. This would ensure that the client receives immediate medical attention and that the client’s condition can be monitored during transport.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Answer and explanation
The correct answer is Choice D.
Choice A rationale
While having 80% of students participate in a voluntary sex education seminar is a positive outcome, it does not directly indicate the success of a pregnancy prevention program.
Participation in a seminar does not necessarily translate into behavior change. Students may attend the seminar but not apply the knowledge or skills learned, which would not result in a decrease in teenage pregnancies.
Choice B rationale
A reported average delay of 2 years for the first sexual encounter among students can be seen as a positive outcome, as it may reduce the risk of teenage pregnancies. However, this delay does not guarantee that students are using effective contraception when they do start having sex. Therefore, while this outcome may contribute to the success of a pregnancy prevention program, it is not the strongest evidence of success.
Choice C rationale
Parental support for a pregnancy prevention program in schools is important for the program’s implementation and sustainability. However, parental support does not directly result in a decrease in teenage pregnancies. Parents can be supportive of the program, but if the students do not apply the knowledge or skills learned, the number of teenage pregnancies may not decrease.
Choice D rationale
A decrease in the number of teenage pregnancies in the school district is the strongest evidence of the program’s success. This outcome directly aligns with the goal of a pregnancy prevention program, which is to reduce the number of teenage pregnancies. If the school district reports a decrease in the number of teenage pregnancies, it indicates that the program is effectively helping students to prevent pregnancies.
Correct Answer is C
Explanation
Answer and explanation
The correct answer is C.
Choice A rationale
Patches of round lesions on both lower legs could be a sign of a skin condition such as ringworm. However, this condition is typically not urgent and can be treated with over-the- counter antifungal creams.
Choice B rationale
Red ring-shaped lesions with normal skin in the center could be a sign of ringworm. While this condition should be treated, it is not typically considered urgent.
Choice C rationale
Itchy, red, scaly patches with blisters that are draining could be a sign of a serious skin infection such as cellulitis. This condition can spread quickly and become serious if not treated promptly, so it should be prioritized for immediate intervention.
Choice D rationale
Several irritated circular bald, flaky scalp patches could be a sign of a scalp condition such as tinea capitis. While this condition should be treated, it is not typically considered urgent.
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