When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

Low intermittent suction prescribed for the nasogastric tube is turned off.

A Hemovac drain is partially full of serous drainage and is not compressed.

The urinary catheter drainage bag is almost completely full of amber urine.

Oxygen is being administered via nasal cannula at 4 L/minute without humidification.

Answer and Explanation

The Correct Answer is D

A. This requires prompt attention but is not immediately life-threatening.

B.   This requires attention but does not pose an immediate threat to the client's condition.

C.   An almost completely full urinary catheter drainage bag requires attention but does not pose an immediate threat to the client's condition.
D.   Administering oxygen without humidification could lead to mucosal dryness and damage, and should be addressed promptly.

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Correct Answer is B

Explanation

A. A toileting schedule is unnecessary for an anuric client as they do not produce urine.
B. Anemia is a common complication of chronic kidney disease due to reduced erythropoietin production, so monitoring for signs of anemia is important.
C. High potassium foods should be avoided as impaired kidney function can lead to hyperkalemia.
D. While perineal skin care is important, it is not as critical as monitoring for anemia in this context.

Correct Answer is ["1.4"]

Explanation

To calculate the dosage of lorazepam for the client, first determine the total micrograms required by multiplying the client's weight in kilograms by the prescribed amount per kilogram. For a client weighing 65 kg prescribed 44 mcg/kg, the total dosage would be 65 kg x 44 mcg/kg, which equals 2860 mcg. Since the medication is available in a concentration of 2 mg/ml, convert the total dosage from micrograms to milligrams by dividing by 1000 (because there are 1000 micrograms in a milligram). This results in 2.86 mg. Finally, to find out how many milliliters to administer, divide the total milligrams needed by the concentration of the vial, which is 2 mg/ml. Therefore, 2.86 mg / 2 mg/ml equals 1.43 ml. When rounding to the nearest tenth, the nurse should administer 1.4 ml of lorazepam.

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When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

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Naxlex Comprehensive Predictor Exams

The nurse is planning care for a client with chronic kidney disease who is a resident at a long-term nursing facility. The client is anuric and has hemodialysis 3 times a week. Which intervention should the nurse include in the client's plan of care?

Correct Answer is B

Explanation

Correct Answer is ["1.4"]

Explanation

Exhibits Nursing actions: Indicated/contraindicated/non-urgent

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When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

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