Questions 54

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Gastrointestinal NCLEX RN Questions Questions

Extract:


Question 1 of 5

The nurse cares for a client four days postoperative following an open splenectomy. The client's vital signs are T 101.1°F (38.4°C), P 92, RR 17, BP 152/86, and pulse oximetry reading 95% on oxygen at 2 L/min via nasal cannula. The surgical wound is assessed to have erythema and purulent drainage. The nurse should take which actions? Select all that apply.

Correct Answer: A,B,D

Rationale: Fever, erythema, and purulent drainage suggest infection, requiring notifying the physician (
B), requesting antibiotics (
A), and obtaining blood cultures (
D). Ambulation (
C) and increasing oxygen (E) are not indicated.

Question 2 of 5

Correct Answer:

Rationale:

Question 3 of 5

Correct Answer:

Rationale:

Question 4 of 5

Correct Answer:

Rationale:

Question 5 of 5

Correct Answer:

Rationale:

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