The nurse is caring for a postoperative client who has a saline lock and minimal urine in the drainage bag, who appears anxious and restless. The nurse notices that the client's hands are cool and moist, with prolonged capillary refill. Which action should the nurse take?

Place a warm blanket on the client.

Administer IV fluids per protocol.

Review the medication administration record.

Check the urinary catheter r an occlusion.

Answer and Explanation

The Correct Answer is B

A. Place a warm blanket on the client: Providing warmth may improve comfort temporarily but does not address the underlying cause of the client’s cool, moist hands, prolonged capillary refill, or low urine output, which suggest possible hypovolemia or shock.

B. Administer IV fluids per protocol: The client’s signs restlessness, cool clammy skin, prolonged capillary refill, and low urine output indicate hypoperfusion likely due to fluid deficit. Administering IV fluids promptly helps restore circulating volume and tissue perfusion.

C. Review the medication administration record: While medication review is important for overall safety, it does not address the immediate risk of hypovolemic shock or low urine output in this client.

D. Check the urinary catheter for an occlusion: Although checking for blockage is reasonable if a catheter is present, the client’s overall clinical presentation points to systemic hypovolemia rather than a localized urinary obstruction.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is ["1.3"]

Explanation

Convert the infant's weight from pounds (lb) to kilograms (kg).

Given weight = 22 lb

Conversion factor = 1 kg = 2.2 lb

Weight (kg) = (Weight in lb / 2.2 lb/kg)

= (22 / 2.2)

= 10 kg.

Calculate the total daily dose in milligrams (mg/day).

Prescribed dose = 20 mg/kg/day

Total Daily Dose (mg/day) = Weight (kg) x Dose (mg/kg/day)

= 10 kg x 20 mg/kg/day = 200 mg/day.

Calculate the single dose in milligrams (mg/dose).

Frequency = every 8 hours (3 doses per day)

Single Dose (mg/dose) = (Total Daily Dose / Number of doses per day)

= (200 mg / 3)

= 66.67 mg.

Calculate the volume in milliliters (mL) to administer per dose.

Available concentration = 250 mg per 5 mL

Volume (mL/dose) = (Single Dose (mg) / Available concentration (mg)) x Available volume (mL)

= (66.67 mg / 250 mg) x 5 mL

= 1.333... mL.

Round the answer to the nearest tenth.

= 1.3 mL.

A. Heart rate: 128 beats/minute, sinus tachycardia (ST) B. Blood pressure: 90/79 mm Hg, pulse pressure less than 40 mm Hg C. The client's surgical dressing is clean and dry D. Ecchymosis noted on the abdomen around the dressing. E. Heart sounds are regular. F. Capillary refill is 6 seconds. G. The client has an indwelling urinary catheter in place. No urine noted.

Correct Answer is ["A","B","F","G"]

Explanation

Rationale for correct choices

• Heart rate 128 beats/minute, sinus tachycardia: Tachycardia signals early compensatory response to hypovolemia or hemorrhagic shock, common with abdominal trauma. Immediate attention is needed to prevent cardiovascular collapse.
• Blood pressure 90/79 mm Hg, pulse pressure less than 40 mm Hg: A narrow pulse pressure with low systolic BP suggests inadequate stroke volume and poor perfusion, consistent with ongoing internal bleeding.
• Capillary refill 6 seconds: Prolonged refill indicates impaired peripheral perfusion and circulatory compromise, reinforcing concerns of shock.
• No urine output: Absence of urine is a critical marker of inadequate renal perfusion and systemic hypoperfusion, reflecting worsening shock status.

Rationale for incorrect choices

• Temperature 96.9° F (36.1° C): Slightly low but not critical; mild hypothermia is common post-trauma and can be managed after stabilizing perfusion.
• Surgical dressing clean/dry with ecchymosis: Ecchymosis is expected after trauma and surgery, requiring monitoring but not immediate intervention.
• Heart sounds regular, lung sounds clear: No acute cardiopulmonary decompensation detected.

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The nurse is caring for a postoperative client who has a saline lock and minimal urine in the drainage bag, who appears anxious and restless. The nurse notices that the client's hands are cool and moist, with prolonged capillary refill. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["1.3"]

Explanation

Correct Answer is ["A","B","F","G"]

Explanation

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