Which of the following post-surgical clients warrant an immediate follow up by the nurse? (Select all that apply.)

Patient with lung surgery has 20 ml/hr of urine output via catheter.

Patient with appendix surgery has thready pulse and blood pressure is 90/60.

Patient with knee surgery has approximated incision.

Patient with femoral artery surgery has strong pedal pulse.

Patient with bladder surgery has bloody urine within the first 12 hours.

Answer and Explanation

Correct Answer : A,B,E

A.   A urine output of 20 ml/hr is considered inadequate and may indicate decreased kidney perfusion or function. This client likely needs immediate assessment and intervention to address potential renal complications.
B.   A patient with appendix surgery exhibiting a thready pulse and a blood pressure of 90/60 should be followed up immediately, as these signs can indicate shock, which is a medical emergency.
C.   An approximated incision indicates that the wound edges are well-aligned and healing is progressing as expected. This does not typically warrant immediate follow-up unless there are signs of infection or other complications.
D.   A strong pedal pulse suggests adequate blood flow distal to the surgical site. This is a positive finding and does not typically require immediate follow-up unless there are signs of vascular compromise or other complications.
E.   A patient with bladder surgery having bloody urine within the first 12 hours can be expected, but if the bleeding is heavy or increases, it would warrant immediate follow-up.

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Correct Answer is D

Explanation

A. Respiratory alkalosis is characterized by a high pH (alkaline) and a low PaCO2 (<35 mm Hg). The ABG results provided show a pH of 7.3 (which is acidic) and a PaCO2 of 50 mm Hg (which is elevated). Therefore, these results do not indicate respiratory alkalosis.
B. Metabolic acidosis is characterized by a low pH (<7.35) and a decreased bicarbonate (HCO3-). The ABG results show a pH of 7.3 (acidic), which aligns with metabolic acidosis. However, the PaCO2 of 50 mm Hg is elevated, which typically indicates respiratory compensation for the metabolic acidosis.
C. Metabolic alkalosis is characterized by a high pH and an elevated bicarbonate (HCO3-). The ABG results show a pH of 7.3 (acidic), which does not suggest metabolic alkalosis.
D. Respiratory acidosis is characterized by a low pH and an elevated PaCO2 (>45 mm Hg). The ABG results provided show a pH of 7.3 (acidic) and a PaCO2 of 50 mm Hg (elevated). These findings are consistent with respiratory acidosis, where the elevated PaCO2 indicates retention of carbon dioxide, leading to acidosis.

A. pH 7.45 B. HCO3- 30 mEq/L C. Potassium 3.3 mEq/L D. PaCO2 50 mm Hg

Correct Answer is D

Explanation

A. A pH of 7.45 indicates alkalosis, not acidosis. In respiratory acidosis, the pH would be lower than normal (below 7.35) due to the accumulation of carbon dioxide.
B. A bicarbonate (HCO3-) level of 30 mEq/L is within the normal range (typically 22-26 mEq/L). Bicarbonate levels may be normal or slightly elevated in respiratory acidosis as a compensatory mechanism to buffer the excess acid.
C. Potassium levels can vary in respiratory acidosis but are not typically specified by a specific value. The level of potassium is more directly related to metabolic acid-base disturbances rather than respiratory acidosis.
D. An elevated PaCO2 level above 45 mm Hg indicates respiratory acidosis. In this scenario, a PaCO2 of 50 mm Hg suggests that the client is retaining carbon dioxide, leading to an acidotic state (lower pH).

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Which of the following post-surgical clients warrant an immediate follow up by the nurse? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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