A nurse is caring for a client who is postoperative following an appendectomy.
Vital Signs
1800:
Temperature 98.4° F (36.8° C) Heart rate 104/min
Respiratory rate 22/min
Blood pressure 142/80 mm Hg
O2 saturation 97% on room air
1800:
Client alert and oriented x 4
Skin warm and dry
Lungs clear on auscultation
Bowel sounds hypoactive in all four quadrants Urine clear yellow
Incisional dressing clean and dry
Client reports pain as 6 on a scale of 0 to 10
1815:
Morphine administered as prescribed
2000:
Temperature 98.4° F (36.8° C) Heart rate 110/min Respiratory rate 24/min
Blood pressure 158/88 mm Hg O2 saturation 93% on room air
Which of the following 4 client findings should the nurse report to the provider?
Bowel sounds
Oxygen saturation
Nausea
Vomiting
Pain level
Heart rate
Incision characteristics
Lungs sounds
Correct Answer : B,D,E,F
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.This action is the best first step as it engages staff members directly in identifying the underlying causes of staffing difficulties. Involving staff in the problem-solving process can lead to more effective solutions and promote buy-in for any changes.
B.While supporting staff is important, this step should come after understanding the issues and gathering input. Addressing resistance without first identifying the root causes may not be effective.
C.While communication is important, presenting options without first gathering input and understanding the current issues may not address the root problems. A meeting should follow the investigation and data collection.
D.Notifying staff of changes is important, but it should come after the issues are investigated and a plan is formed. Implementing changes without understanding staff concerns may lead to further dissatisfaction.
Correct Answer is B
Explanation
A. Heart rate 136/min is a normal finding for a newborn. The normal range of heart rate for a newborn is 100 to 160/min.
B. Nasal flaring is an abnormal finding for a newborn. Nasal flaring indicates respiratory distress and may be caused by conditions such as pneumonia, meconium aspiration, or congenital heart defects.
C. Transient strabismus is a normal finding for a newborn. Transient strabismus is a temporary misalignment of the eyes that occurs due to weak eye muscles and poor coordination. It usually resolves by 3 to 6 months of age.
D. Overlapping of sutures is a normal finding for a newborn. Overlapping of sutures is caused by molding of the skull during delivery and allows the head to fit through the birth canal. It usually resolves within a few days after birth.
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