The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication?

A pulse of 86 beats/minute

Hypoactive bowel sounds in all 4 quadrants

Blood pressure of 110/70 mm Hg

Increasing restlessness

Answer and Explanation

The Correct Answer is D

Choice A Reason:

A pulse of 86 beats per minute is within the normal range for adults (60-100 beats per minute) and does not typically indicate a postoperative complication. While it is important to monitor vital signs, this pulse rate alone is not concerning unless accompanied by other abnormal findings.

Choice B Reason:

Hypoactive bowel sounds in all four quadrants can occur after surgery due to the effects of anesthesia and the surgical procedure itself. While it is important to monitor bowel sounds, hypoactivity is not immediately concerning unless it persists or is accompanied by other symptoms such as abdominal pain or distention. Therefore, this finding alone does not indicate an evolving complication.

Choice C Reason:

A blood pressure of 110/70 mm Hg is within the normal range for adults and does not typically indicate a postoperative complication. Blood pressure should be monitored regularly, but this reading alone is not concerning unless there are significant changes or other abnormal findings.

Choice D Reason:

Increasing restlessness is a concerning sign in the immediate postoperative period. It can indicate several potential complications, including pain, hypoxia, or the onset of delirium. Restlessness may also be an early sign of shock or other serious conditions that require prompt intervention. Therefore, this symptom warrants further assessment and immediate attention to determine the underlying cause and provide appropriate treatment.

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Correct Answer is A

Explanation

Choice A Reason:

0.45% sodium chloride (half-normal saline) is an appropriate solution for treating hypernatremia, especially in a client who is NPO (nothing by mouth). This hypotonic solution helps to gradually reduce the serum sodium levels by providing free water to the extracellular space, which dilutes the high sodium concentration. It is essential to administer this solution slowly to avoid rapid shifts in fluid balance, which can lead to cerebral edema.

Choice B Reason:

Dextrose 5% in 0.9% sodium chloride (D5NS) is not the best choice for treating hypernatremia. While it provides some free water, the presence of 0.9% sodium chloride makes it an isotonic solution, which does not effectively lower serum sodium levels. This solution is more suitable for maintaining fluid balance rather than correcting hypernatremia.

Choice C Reason:

Lactated Ringer’s is also not appropriate for treating hypernatremia. This isotonic solution contains electrolytes, including sodium, which can exacerbate hypernatremia rather than correct it. Lactated Ringer’s is typically used for fluid resuscitation and electrolyte replacement in other clinical scenarios.

Choice D Reason:

Dextrose 10% in water (D10W) is a hypertonic solution and is not suitable for treating hypernatremia. While it provides free water, the high concentration of dextrose can lead to rapid shifts in fluid balance and potential complications such as hyperglycemia. This solution is generally used for providing calories and preventing hypoglycemia in specific clinical situations.

Correct Answer is ["31"]

Explanation

Step 1: Calculate the total infusion time in minutes.

8 hours × 60 minutes/hour = 480 minutes

Result at each step = 480 minutes

Step 2: Calculate the total number of drops to be infused.

1,000 mL × 15 drops/mL = 15,000 drops

Result at each step = 15,000 drops

Step 3: Calculate the infusion rate in drops per minute.

15,000 drops ÷ 480 minutes = 31.25 drops/minute

Result at each step = 31.25 drops/minute

Step 4: Round to the nearest whole number if necessary.

31.25 drops/minute rounds to 31 drops/minute

Result at each step = 31 drops/minute

Therefore, the nurse should run the IV infusion at a rate of 31 drops per minute.

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The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client?

Correct Answer is A

Explanation

Exhibits You retrieved regular insulin 100 units in 1 ml. How many ml should you administer? Note Enter ONLY the number DO NOT enter the unit(s) of measurement

Correct Answer is ["31"]

Explanation

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