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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. Asthma: While asthma can cause dyspnea and fatigue, it is not typically associated with tachycardia and edema.
b. Heart failure: Heart failure is characterized by symptoms such as dyspnea, fatigue,
tachycardia, and edema. Tachycardia may be a compensatory response to maintain cardiac output, and edema can result from fluid retention.
c. Aortic valve regurgitation: Aortic valve regurgitation may cause symptoms such as dyspnea and fatigue, but it is not typically associated with tachycardia and edema.
d. Aortic stenosis: Aortic stenosis may lead to symptoms such as dyspnea, but tachycardia and edema are not typical features of aortic stenosis.
Correct Answer is C
Explanation
a. Hyperactive bowel sounds: Shock is more likely to be associated with decreased bowel sounds rather than hyperactive bowel sounds.
b. Increased urine output: In the early stages of shock, there may be an increase in urine output as the body attempts to compensate. However, as shock progresses, renal perfusion decreases,
leading to decreased urine output.
c. Hypotension: Hypotension is a key indicator of shock. In shock, there is insufficient blood flow to meet the body's oxygen and nutrient needs, resulting in a drop in blood pressure.
d. Bradycardia: Shock typically leads to an increased heart rate (tachycardia) as the body tries to compensate for decreased cardiac output. Bradycardia is not a typical finding in the early stages of shock.
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