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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. Urine in the drainage appliance: The presence of urine in the drainage appliance is expected in a client with an ileal conduit, as this is the route for urine to exit the body.
b. Feces in the drainage appliance: An ileal conduit is created for urinary diversion, and feces
should not be present in the drainage appliance. This finding could indicate a complication and should be reported.
c. Mild edema of the stoma: Mild edema of the stoma may be expected in the early postoperative period and may not require immediate reporting unless it worsens.
d. Redness of the stoma: Some redness is normal around a stoma, and it may not require immediate reporting unless there are signs of infection or worsening inflammation.
Correct Answer is B
Explanation
a. Instruct the client to tilt her head back when she swallows: This action is not recommended, as it increases the risk of aspiration. Tilted head positions can lead to improper bolus control and
swallowing difficulties.
b. Add thickener to fluids: This is an appropriate intervention for a client with dysphagia, as thickened fluids are easier to control during swallowing and reduce the risk of aspiration.
c. Place food on the left side of the client's mouth: This action may not directly address the risk of aspiration associated with dysphagia and left-sided weakness.
d. Serve food at room temperature: While serving food at room temperature may be preferred for some clients, it does not directly address the safety concerns associated with dysphagia and left- sided weakness.
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