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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","C","D"]

Explanation

A. Monitor intake and output every shift: Important for tracking fluid balance and ensuring appropriate hydration and nutritional support.
B. Change the IV tubing every seven (7) days: IV tubing should generally be changed every 24 to 72 hours or as per hospital protocol, not every seven days.
C. Place the solution on an IV pump at the prescribed rate: Ensures accurate administration of TPN and prevents complications associated with over or under-infusion.
D. Monitor blood glucose every one (1) hour: Frequent monitoring is required as TPN can cause fluctuations in blood glucose levels.
E. Weigh the client weekly, first thing in the morning: While weighing the client is important, it is typically done more frequently than weekly to monitor fluid status and nutritional response.

A. Furosemide (Lasix) B. Diazepam (Valium) C. Calcium gluconate D. Calcitonin

Correct Answer is C

Explanation

A. Furosemide (Lasix): This is a diuretic used to treat fluid retention and does not address the symptoms related to calcium imbalances.
B. Diazepam (Valium): This is an anxiolytic and does not address the symptoms associated with hypocalcemia following a thyroidectomy.
C. Calcium gluconate: This is the appropriate medication for treating hypocalcemia, which can occur after a thyroidectomy due to potential damage to or removal of parathyroid glands, leading to symptoms such as abdominal cramping and irregular heart rate.
D. Calcitonin: While this hormone helps regulate calcium levels, it is more commonly used to treat hypercalcemia, not hypocalcemia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client is NPO and is receiving total parenteral nutrition (TPN) via a peripherally inserted central catheter. Which precautions should the nurse implement? (Select All That Apply)

Correct Answer is ["A","C","D"]

Explanation

Correct Answer is C

Explanation

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

A nurse is providing education in a community setting to several clients taking daily calcium supplements and encourages them to drink 2,500 mL of fluid daily. The nurse explains that this intervention is important to prevent which complication?

The nurse is asked to witness surgical consent forms were obtained for clients, in the preoperative holding area. What client would not be able to consent legally to surgery?

A client with uncontrolled diabetes mellitus develops metabolic acidosis. Which assessment finding related to the imbalance indicates that the client's compensatory mechanisms are working?

The nurse is reviewing serum laboratory test results of a client receiving diuretic therapy. The nurse determines the client is at risk for electrolyte imbalance based on which result(s)? (Select all that apply)

After receiving the change of shift report, the nurse reviews the electronic health record for each client. What client should the nurse see first?

A client who takes furosemide (Lasix) and propranolol (Inderal) is scheduled for breast reconstruction surgery. Which additional client information requires prompt collaboration with the healthcare provider before surgery?

A nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL. Which condition most likely caused this serum phosphorus level?