The practical nurse (PN) is providing care for a client who is ordered nothing by mouth (NPO) after a small bowel resection. The client's nasogastric (NG) tube is connected to low intermitent suction. The client reports dizziness and tingling in digits.
Which assessment finding by the PN should be reported to the healthcare provider?
Hyperactive bowel sounds on assessment.
Heart rate of 90 beats per minute with premature ventricular contractions (PVCs) noted on telemetry.
Hypoactive bowel sounds on assessment
Regular heart rate of 100 beats per minute on telemetry
The Correct Answer is B
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is the finding that the PN should report to the charge nurse because it indicates a possible complication of Guillain-Barre syndrome, which is autonomic dysfunction. This can affect the cardiac, respiratory, and gastrointestinal systems and cause life-threatening problems such as arrhythmias, hypotension, or respiratory failure. The PN should monitor the client's vital signs closely and report any abnormal changes.
B. Profuse diaphoresis is not a priority finding and may be related to other factors such as fever, anxiety, or medication side effects.
C. Lower leg weakness is an expected finding in Guillain-Barre syndrome and does not need to be reported unless it progresses rapidly or affects the respiratory muscles.
D. Full facial flushing is not a priority finding and may be related to other factors such as vasodilation, inflammation, or medication side effects.
Correct Answer is B
Explanation
The correct answer is B. Extend the leg and flex the foot.
Choice A rationale:
Massaging the calf and foot is not recommended as it could potentially dislodge a blood clot if one is present, which can be dangerous.
Choice B rationale:
Extending the leg and flexing the foot helps to relieve the cramp by stretching the muscles involved. This is a safe and effective method to alleviate muscle cramps.
Choice C rationale:
Checking the pedal pulse in the affected leg is important for assessing circulation but does not directly address the immediate discomfort of the cramp.
Choice D rationale:
Elevating the leg above the heart is generally used to reduce swelling and improve circulation but is not specifically effective for relieving muscle cramps.
: 3
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