The nurse is obtaining vital sign measurements every 15 minutes for a client who had an emergency appendectomy and currently has a temperature of 101.4°F (38.6°C). Which vital sign measurements should the nurse report to the healthcare provider?

Heart rate 80 beats/minute, respirations 18 breaths/minute, and blood pressure 140/70 mmHg.

Heart rate 110 beats/minute, respirations 22 breaths/minute, and blood pressure 88/56 mmHg.

Heart rate 62 beats/minute, respirations 19 breaths/minute, and blood pressure 150/90 mmHg.

Heart rate 100 beats/minute, respirations 24 breaths/minute, and blood pressure 118/68 mmHg.

Answer and Explanation

The Correct Answer is B

Choice A reason: These vital signs are within normal limits and do not indicate an immediate concern that requires reporting to the healthcare provider.

Choice B reason: This set of vital signs shows a heart rate of 110 beats/minute, which is tachycardia, and a blood pressure of 88/56 mmHg, which is hypotension. Both of these findings, combined with the client's fever, could indicate sepsis or other complications that require immediate attention.

Choice C reason: These vital signs are relatively stable and do not indicate a critical issue that requires immediate reporting.

Choice D reason: While these vital signs show an elevated respiratory rate, they are not as critical as the vital signs in Choice B, which show hypotension and tachycardia.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: Decreasing dietary fat intake can be beneficial for overall health, but it is not specifically related to managing diverticulitis. Dietary fat does not directly influence the inflammation of diverticula.

Choice B reason: Increasing fluids and dietary fibber is important for preventing diverticulosis, which is the presence of diverticula in the colon. However, during an acute episode of diverticulitis, high fibber can exacerbate symptoms. Therefore, this recommendation is not appropriate during active inflammation.

Choice C reason: Ingesting frequent small meals can aid in digestion and prevent large meals from causing discomfort, but it does not directly address the dietary needs during diverticulitis.

Choice D reason: Reducing roughage in the diet is crucial during an acute episode of diverticulitis. High-fibber foods and roughage can irritate the inflamed diverticula and worsen symptoms. A low-fibber diet is often recommended until the inflammation subsides, after which a gradual return to a high-fibber diet can be beneficial to prevent future episodes.

A. Decrease foods high in fat or trans fats. B. Eliminate caffeine and chocolate. C. Augment intake of dairy products. D. Increase intake of insoluble fibber.

Correct Answer is D

Explanation

Choice A reason: Decreasing foods high in fat or trans fats is generally good for overall health, but it is not specifically related to managing diverticulosis. Focusing on fibber intake is more important for this condition.

Choice B reason: Eliminating caffeine and chocolate might be helpful for certain digestive issues, but it is not directly related to diverticulosis management. The primary concern for diverticulosis is to ensure adequate fibber intake to promote regular bowel movements and prevent complications.

Choice C reason: Augmenting the intake of dairy products is not directly beneficial for diverticulosis and could potentially cause discomfort in individuals who are lactose intolerant. It is not a recommended dietary modification for this condition.

Choice D reason: Increasing the intake of insoluble fibber is crucial for managing diverticulosis. Insoluble fibber helps to increase stool bulk and promote regular bowel movements, which can reduce the risk of diverticula formation and prevent flare-ups of diverticulitis. Foods rich in insoluble fibber include whole grains, vegetables, and fruits.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is obtaining vital sign measurements every 15 minutes for a client who had an emergency appendectomy and currently has a temperature of 101.4°F (38.6°C). Which vital sign measurements should the nurse report to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which diet modification should the nurse suggest to a client who was recently diagnosed with diverticulitis?

Correct Answer is D

Explanation

The nurse plans to provide diet instructions to a client who was recently diagnosed with diverticulosis. Which dietary modification should the nurse include in the teaching plan?

Correct Answer is D

Explanation

A client who is receiving normal saline IV at 75 mL/hour has dry, sticky mucous membranes, and inelastic skin turgor. Which action should the nurse implement?

A client is newly diagnosed with type 2 diabetes mellitus. The nurse is educating the client about self-monitoring blood glucose (SMBG) and haemoglobin A1C. Which statement by the client indicates teaching has been effective?

The home health nurse visits a client who has a serum sodium level of 123 me/L (123 mmol/L). To explore possible etiologist for this value, what question should the nurse ask the client?

The nurse calculates the body mass index (BMI) for an adult client who is obese. Which additional assessment finding places the client at high risk for cardiac disease?

Which statement by a client with systemic lupus erythematosus (SLE) indicates the best understanding of proper skin care?

The nurse is developing a plan of care for a client who reports frequent urination and who is newly diagnosed with type 2 diabetes. Which outcome should the nurse include in the plan of care for this client?

In planning care for a client with chronic ulcerative colitis, which long-term goal is most important for the nurse to include?

A client with ulcerative colitis is admitted to the medical unit during an acute exacerbation. The nurse should instruct the unlicensed assistive personnel (UAP) to report which finding related to the client's bowel movements?