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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Related Questions
Correct Answer is B
Explanation
a. Creatinine 0.9 mg/dL: This creatinine level is within the normal range and is not an immediate priority for knee arthroplasty.
b. WBC count 20,000/mm3: An elevated white blood cell count suggests the presence of
infection or inflammation. In the context of knee arthroplasty, infection is a significant concern and requires immediate attention to prevent complications.
c. Potassium 3.8 mEq/L: This potassium level is within the normal range and is not an immediate priority for knee arthroplasty.
d. Hematocrit 40%: This hematocrit level is within the normal range and is not an immediate priority for knee arthroplasty. The elevated WBC count takes precedence as it suggests a
potential infectious process.
Correct Answer is B
Explanation
a. Maintain the client on bed rest: While rest may be indicated in some cases, it is not a specific intervention for managing renal stones with a urinary catheter.
b. Strain the client's urine through a mesh filter: Straining urine is essential to collect any stones that may have passed, allowing for analysis and identification.
c. Encourage fluid intake of 1500 mL/day: Adequate fluid intake is crucial to prevent stone formation, but the amount may vary depending on the client's specific needs and condition.
d. Clamp the urinary catheter every 2 hr: Clamping the urinary catheter is not a standard
intervention for managing renal stones. Straining the urine for stone collection is a more relevant intervention.
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