The nurse is assessing a 60-year-old client who is 6 hours postoperative from colon resection surgery. Immediate postoperative vital signs were BP 126/78 mmHg, HR 80 bpm, RR 13, and Temp 98.9°F. Current vital signs are BP 105/60 mm Hg, HR 120 bpm, RR 21, and Temp 99.1°F. His skin is pale and cool, and his total urine output is 125 mL over 6 hours. What nursing action is most appropriate?

Continue monitoring the client.

Increase nasal oxygen flow rate to 8 L

Place the client in high Fowler's position.

Notify the surgeon as soon as possible

Answer and Explanation

The Correct Answer is D

A. Continue monitoring the client: The client's vital signs, pale and cool skin, and low urine output suggest potential hypovolemic shock or other serious postoperative complications, requiring more immediate intervention than just continued monitoring.
B. Increase nasal oxygen flow rate to 8 L: While increasing oxygen may be necessary, the primary concern is the underlying cause of the client's symptoms, which may require more immediate intervention.
C. Place the client in high Fowler's position: This position may be beneficial for certain conditions but does not address the underlying issues suggested by the vital signs and physical findings.
D. Notify the surgeon as soon as possible: This is the correct choice. The client's hypotension, tachycardia, pale and cool skin, and low urine output indicate potential complications that need immediate evaluation by the surgeon.

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Correct Answer is B

Explanation

A. Start an IV of DSNS with 40 mEq KCI at 125 mL/hr: Starting an IV is important but may not be the immediate first step. The client's symptoms suggest hypotension, likely due to hypovolemia, which needs immediate positional intervention before fluid administration.
B. Elevate the feet and lower the head: This position, known as the Trendelenburg position, helps increase venous return to the heart and can quickly improve blood pressure and perfusion to vital organs. It is an immediate intervention for hypotension.
C. Call the surgeon and report the vital signs: While important, calling the surgeon is not the first intervention. Immediate action to stabilize the client's condition is necessary before notifying the healthcare provider.
D. Monitor the vital signs every 15 minutes: Monitoring is important, but it is not an immediate intervention. The nurse must first address the client's low blood pressure and symptoms of hypoperfusion before continuing regular monitoring.

A. Reddish streak proximal to the insertion site B. Skin is pale and taut C. The vein is firm and cord-like D. IV fluid leaking from insertion site E. Warmth at the insertion site

Correct Answer is ["B","D","E"]

Explanation

A. Reddish streak proximal to the insertion site: This indicates phlebitis, not infiltration.
B. Skin is pale and taut: This indicates infiltration as fluid accumulates in the surrounding tissue, causing the skin to appear pale and tight.
C. The vein is firm and cord-like: This is typically a sign of phlebitis or thrombophlebitis, not infiltration.
D. IV fluid leaking from insertion site: This is a sign of infiltration where fluid has leaked out of the vein into the surrounding tissue.
E. Warmth at the insertion site: This can indicate infiltration or inflammation, depending on other symptoms present.

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a client in the post-anesthesia care unit. The client's vital signs are T 98°F, P 106, R 24, and BP 88/40. The client is awake and oriented x 3 and the skin is pale and damp. The client denies complaints of pain. What intervention should the nurse implement first?

Correct Answer is B

Explanation

Which of the following assessment findings should alert the nurse that a client's IV has infiltrated? (Select All That Apply)

Correct Answer is ["B","D","E"]

Explanation

The nurse identifies that which of the following clients is at risk for developing metabolic acidosis? (Select All That Apply)

A client has a serum calcium level of 12.8 mg/dL. Which medication will likely be prescribed for this client?

The nurse is caring for a client with a serum magnesium of 2.9 mEq/L. The nurse should anticipate a prescription from the primary healthcare provider for what treatment?

The nurse is providing teaching to the client about the use of vitamins and supplements. The nurse would state that vitamin D has a major role in which process?

The nurse working on a medical surgical unit is assigned four clients at the start of their shift. What client should be given the highest priority?

A client indicates to the nurse a pain level of 8 out of 10. The nurse notes the client has an order for morphine 4 mg IV Q 6 hr PRN for moderate to severe pain. The client's blood pressure is 80/54 mm Hg, respirations 10 breaths/min, and pulse 62 beats/min. Which action should the nurse take?

A client has just undergone a bedside central venous catheter insertion using ultrasound guidance. The nurse knows to check which diagnostic result before initiating the client's prescribed intravenous solution flow rate at 100 mL/hr?