A nurse is monitoring a client who is 12 hr postoperative following a colectomy. Which of the following findings should the nurse report to the provider?

Heart rate 90/min

Serum potassium 3.7 g/dL

Bowel sounds 10/min

Urine output 48 m/2 hr

Answer and Explanation

The Correct Answer is D

a. Heart rate 90/min: A heart rate of 90/min is within the normal range, and it is not an abnormal finding postoperatively.

b. Serum potassium 3.7 g/dL: The serum potassium level of 3.7 g/dL is within the normal range, and it is not an abnormal finding postoperatively.

c. Bowel sounds 10/min: Bowel sounds of 10/min are within the normal range and indicate return of bowel function postoperatively.

d. Urine output 48 m/2 hr: A urine output of 48 m/2 hr is less than the expected urine output (30 mL/hr), and it may indicate inadequate renal perfusion or function. This finding should be

reported to the provider.

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Correct Answer is B

Explanation

b. Paralytic ileus: Absence of bowel sounds, abdominal distention, and no passage of flatus are characteristic signs of paralytic ileus, which is a temporary impairment of bowel motility following surgery.

c. Health care-associated Clostridium difficile: Clostridium difficile infection is associated with diarrhea, abdominal pain, and fever. The absence of bowel sounds and abdominal distention is not consistent with C. difficile infection.

d. Fecal impaction: Fecal impaction is characterized by a blockage of hardened stool in the

rectum or colon, leading to difficulty passing stool. It may cause abdominal discomfort, but it does not typically present with the absence of bowel sounds and abdominal distention seen in paralytic ileus.

A. Tetany B. Constipation C. Negative Chvostek sign D. Elevated blood pressure

Correct Answer is A

Explanation

a. Tetany: A calcium level of 8 mg/dl is low and can be associated with tetany.

b. Constipation:This is associated with hypercalcemia as opposed to hypocalcemia

c. Negative Chvostek sign: A positive Chvostek sign is associated with hypocalcemia, not hypercalcemia.

d. Elevated blood pressure: Elevated calcium levels are not typically associated with elevated blood pressure. Hypertension is not a common manifestation of hypercalcemia.

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A nurse is monitoring a client who is 12 hr postoperative following a colectomy. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

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