The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider?

The 24-hour oral intake is 600 ml greater than the total output.

The patient's temperature is 100.3" F 137.9" C).

The patient reports abdominal pain at level 6 (0 to 10 scale) when ambulating

The patient's calf is swollen, warm, and painful.

Answer and Explanation

The Correct Answer is D

These symptoms suggest the possibility of deep vein thrombosis (DVT), which is a potentially serious complication following surgery. DVT occurs when a blood clot forms in a deep vein, commonly in the lower extremities. The symptoms of a swollen, warm, and painful calf can indicate the presence of a DVT.

DVT is a medical emergency that requires immediate attention and intervention to prevent further complications such as a pulmonary embolism (where the blood clot travels to the lungs). Prompt evaluation and treatment, such as anticoagulant therapy, are necessary to prevent complications

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Correct Answer is A

Explanation

A 3% saline solution is a hypertonic solution used to increase serum sodium levels in cases of severe hyponatremia. However, it can lead to fluid overload and pulmonary edema. The presence of crackles throughout both lung fields indicates the accumulation of fluid in the lungs, which is a serious adverse outcome.

The patient's radial pulse rate of 105 beats/min is within a normal range and does not directly indicate an adverse effect of the saline infusion.

The presence of sediment and blood in the patient's urine may be unrelated to the 3% saline infusion and could indicate other issues such as urinary tract infection or kidney injury.

An increase in blood pressure from 66/50 to 122/74 mmHg is an expected effect of a hypertonic solution like 3% saline, as it can cause an increase in intravascular volume. While the increase in blood pressure is significant, it does not represent an adverse outcome specific to the infusion itself.

A. Decreasing serum chloride levels B. Increasing serum sodium levels C. Increasing serum potassium levels D. Decreasing blood sucrose levels

Correct Answer is B

Explanation

Acute adrenal insufficiency, also known as adrenal crisis, is characterized by low levels of adrenal hormones, particularly cortisol. One of the primary manifestations of adrenal insufficiency is electrolyte imbalance, specifically hyponatremia (low sodium) and hyperkalemia (high potassium). Inadequate cortisol levels can lead to impaired sodium reabsorption in the kidneys, resulting in sodium loss and low serum sodium levels.

When the patient receives appropriate therapies for acute adrenal insufficiency, such as administration of glucocorticoids (e.g., hydrocortisone), the cortisol levels begin to normalize. As a result, the impaired sodium reabsorption improves, leading to an increase in serum sodium levels.

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The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data represents an adverse outcome (side effect) of this infusion?

Correct Answer is A

Explanation

Which finding indicates to the nurse that the current therapies are effective for a patient with acute adrenal insufficiency?

Correct Answer is B

Explanation

A patient is receiving Gabapentin (Neurontin), an anticonvulsant, but has no history of seizures. The nurse expects that the patient is receiving this drug for which condition?

The nurse provides education to a female patient diagnosed with iron deficiency anemia. Which patient statements indicate a correct understanding of iron deficiency? SELECT ALL THAT APPLY

The nurse is providing education to a client who is prescribed Lisinopril (ACE inhibitor) for hypertension. The nurse will be sure to include what information about a common side effect?

The nurse is administering nitroprusside by IV infusion for a client in hypertensive emergency. The nurse knows that the primary assessment will be:

A client's Sodium level is 128 meq/L. The nurse knows that a likely cause of this lab finding is:

An appropriate nursing intervention to minimize separation anxiety in a hospitalized toddler is to:

The nurse is caring for an infant with a hip spica cast who has just returned from surgery. Which nursing action will be priority for this patient?