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.

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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. Send the client to x-ray for a flat plate of the abdomen. B. Give a prescribed analgesic for temperature above 101°F (38.3°C). C. Place an indwelling urinary catheter and attach to a bedside drainage unit. D. Insert a nasogastric tube (NGT) and attach to low intermittent suction.

Correct Answer is D

Explanation

Choice A reason: Sending the client to x-ray for a flat plate of the abdomen is important for diagnosing the underlying cause of symptoms, such as bowel obstruction or severe inflammation. However, in the immediate situation, it is essential to relieve the client's symptoms and stabilize their condition first.

Choice B reason: Giving a prescribed analgesic for temperature above 101°F (38.3°C) can help manage fever and pain. However, it is not the first priority. The client’s primary issue is abdominal cramping, nausea, and vomiting, which need to be addressed urgently to prevent further complications.

Choice C reason: Placing an indwelling urinary catheter and attaching it to a bedside drainage unit may be necessary if there are urinary retention concerns. However, this intervention does not directly address the gastrointestinal symptoms that are currently most troubling for the client.

Choice D reason: Inserting a nasogastric tube (NGT) and attaching it to low intermittent suction is the most immediate priority. This action helps to decompress the stomach, relieve nausea and vomiting, and prevent further complications such as aspiration or worsening of the obstruction. It provides immediate symptomatic relief and allows for better management of the client's condition.

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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?

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