During a two-week postoperative follow-up home visit, a client who had gastric bypass surgery exhibits abdominal tenderness, referred shoulder pain, and describes feelings of malaise. The client's vital signs are: temperature 101.8° F (38.8° C), heart rate 104 beats/minute, respirations 18 breaths/minute, and blood pressure 100/50 mm Hg. Which action should the nurse take?

Recheck the client's vital signs in 30 minutes.

Determine the client's current oxygen saturation percentage.

Instruct the client to drive to the hospital for admission.

Have the client transported via ambulance to the hospital.

Answer and Explanation

The Correct Answer is D

Choice A reason: Rechecking vital signs in 30 minutes delays critical intervention. The client is showing signs of a potentially life-threatening postoperative complication such as an anastomotic leak or internal hernia, which can rapidly deteriorate. Delaying action could result in worsening sepsis or bowel ischemia.

Choice B reason: While assessing oxygen saturation is part of a comprehensive evaluation, it does not address the underlying cause of the symptoms. The client’s fever, tachycardia, hypotension, and referred shoulder pain suggest peritoneal irritation and possible sepsis, which require immediate transport and surgical evaluation.

Choice C reason: Instructing the client to drive themselves is unsafe. The client is hemodynamically unstable and may deteriorate en route. Driving could delay care and increase risk of injury or death.

Choice D reason: Transporting the client via ambulance ensures rapid access to emergency care and allows for monitoring during transit. The symptoms are consistent with a surgical emergency such as an anastomotic leak or internal hernia, which require prompt imaging and possible surgical intervention.

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Correct Answer is C

Explanation

Choice A reason: Poor appetite and frequent crying are common post-immunization reactions in infants. These symptoms typically resolve within 24–48 hours and do not indicate a serious adverse event unless they persist or worsen.

Choice B reason: Redness at the injection site is a normal inflammatory response and usually resolves without intervention. It is not considered a reportable adverse reaction unless accompanied by swelling, induration, or signs of infection.

Choice C reason: Clear nasal drainage and cough may indicate a concurrent viral infection or an atypical response to the vaccine. These symptoms are not typical post-vaccine effects and may warrant further evaluation to rule out respiratory illness or allergic reaction.

Choice D reason: An axillary temperature of 100.8°F (38.2°C) is a mild fever and a common post-vaccination response. It does not require reporting unless it exceeds 104°F (40°C) or is accompanied by other concerning symptoms such as seizures or lethargy.

A. Help the residents plan a campaign to remind people driving through the school zone to wear seatbelts at all times. B. Lead a discussion about the benefits of designated safe houses located throughout the school neighborhood. C. Encourage residents with older homes along the school route to get their homes inspected for excessive lead levels. D. Advise the residents to keep their porch lights on during hours that children are walking to and from school.

Correct Answer is B

Explanation

Choice A reason: Seatbelt campaigns are important for vehicle safety but do not directly impact pedestrian safety for children walking to school. The focus should be on protecting children in transit, not drivers.

Choice B reason: Designated safe houses provide children with secure locations to seek help if they feel threatened or unsafe while walking. This strategy directly enhances pedestrian safety and community engagement.

Choice C reason: Lead inspections are important for environmental health but are unrelated to the immediate safety of children walking to and from school. This action does not address the PTO’s goal.

Choice D reason: Keeping porch lights on improves visibility and may deter crime, but it is a passive measure. It does not offer direct support or protection for children in distress.

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Naxlex Comprehensive Predictor Exams

The nurse is teaching a mother about caring for her 6-month-old infant following the administration of routine immunizations. Which finding should the nurse explain to the mother to report to the healthcare provider?

Correct Answer is C

Explanation

The nurse is working with a Parent Teacher Organization (PTO) to increase safety for children walking to and from a nearby elementary school. Which action should the nurse include to help achieve this goal?

Correct Answer is B

Explanation

The nurse is caring for four clients in a women's health clinic. Which client should the nurse assess for risk for pelvic inflammatory disease (PID)?

While performing health screenings at a community health fair, the nurse reviews data obtained from four clients. Which client information has the highest priority for follow-up intervention?

When visiting a community health clinic, a client's blood pressure is measured at 146/94 mm Hg. Which information should the nurse provide the client?

The nurse is teaching a group of young adults at a health fair about skin health and tanning. Which information should the nurse include in the presentation?

According to the Centers for Disease Control and Prevention, which diseases are reportable infectious diseases? Select all that apply.

An older adult client visits the community health clinic and reports the onset of pain, redness, and swelling of the right eye. Which question is most important for the clinic nurse to ask the client?