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. Neck vein distention: Neck vein distention may indicate fluid overload, but it is not a direct measure of fluid losses.
b. Body weight: Monitoring body weight before and after hemodialysis provides a direct
measure of fluid losses. Hemodialysis removes excess fluid, and changes in body weight reflect fluid balance.
c. Abdominal girth: Abdominal girth may be affected by fluid accumulation but is not a direct measure of fluid losses during hemodialysis.
d. Blood pressure: While blood pressure may be influenced by fluid status, it is not a specific measure of fluid losses during hemodialysis. Body weight is a more direct indicator of fluid removal.
Correct Answer is A
Explanation
A. “You may feel some cramping during the procedure.” - This response provides an honest and accurate expectation of potential discomfort during the colonoscopy.
B. “Don’t worry, you won’t remember anything about the procedure due to the effects of the medication.” - Sedation may help with recall, but it doesn't eliminate the possibility of feeling discomfort.
C. “Most clients report more discomfort from the preparation than from the procedure itself.” - While this statement is generally true, it doesn't directly address the client's concern about pain during the colonoscopy.
D. “You shouldn’t feel any pain since the local area is anesthetized.” - Colonoscopy is typically done with conscious sedation rather than local anesthesia, and some discomfort may still be felt.
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