A client, who is 4 hours postoperative laparotomy, has rapidly increasing abdominal distention with elevated pulse and respiratory rates. The client's skin is cool and pale, and there is no change in the blood pressure. Which intervention should the nurse implement immediately?

Measure the client's abdominal girth.

Monitor the client's recent hemoglobin levels.

Prepare for nasogastric tube (NGT) insertion.

Notify the healthcare provider (HCP) of the client's status.

Answer and Explanation

The Correct Answer is D

A. Measure the client's abdominal girth. While tracking abdominal distension is useful, it does not address the underlying cause of the client's deterioration. Measuring girth should not delay immediate intervention for a potentially life-threatening condition.
B. Monitor the client's recent hemoglobin levels. A drop in hemoglobin would indicate internal bleeding, but waiting for lab results could delay necessary treatment. The client is already showing signs of early shock, requiring urgent medical intervention rather than just monitoring.
C. Prepare for nasogastric tube (NGT) insertion. An NGT may be needed for bowel obstruction or paralytic ileus, but the client's worsening condition suggests a more urgent issue, such as intra-abdominal hemorrhage. Addressing the potential bleeding takes priority over decompression.
D. Notify the healthcare provider (HCP) of the client's status. The client's tachycardia, tachypnea, cool pale skin, and worsening abdominal distension suggest early shock, likely due to postoperative internal bleeding or abdominal compartment syndrome. Immediate notification of the HCP ensures rapid assessment, diagnostic testing, and potential emergency intervention to prevent further deterioration.

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Correct Answer is D

Explanation

A. Prepare to give phenytoin IV as prescribed. Phenytoin is used for seizure prophylaxis in clients with moderate to severe head injuries (GCS ≤ 8–10). A GCS score of 14 indicates mild head injury, and prophylactic anticonvulsants may not be necessary unless ordered for specific risk factors.
B. Perform a substernal rub to evoke a response to pain. A substernal rub (painful stimulus) is used to assess response in unconscious or unresponsive clients (GCS ≤ 8). With a GCS of 14, the client is alert or nearly fully conscious, making a painful stimulus unnecessary and inappropriate.
C. Promptly notify the healthcare provider (HCP) of the GCS score. A GCS of 14 is not a critical or emergency finding, as it indicates mild neurological impairment. While the HCP should be updated on significant changes, routine monitoring is sufficient unless deterioration occurs.
D. Continue monitoring the client's GCS score every 2 hours. Frequent neurological assessments are crucial in head injury management to detect worsening conditions like increasing intracranial pressure (ICP) or cerebral edema. Monitoring the GCS every 2 hours ensures timely intervention if the client’s condition changes.

Correct Answer is ["5"]

Explanation

Calculation:

Calculate the New Nitroglycerin Dose in mcg/hour

Dose (mcg/hour) = Dose (mcg/min) × 60 min/hour

=15 mcg/min × 60 min/hour = 900 mcg/hour

Convert mcg to mg

Dose (mg/hour) = Dose (mcg/hour) / 1000 mcg/mg

=900 mcg/hour / 1000 mcg/mg

= 0.9 mg/hour

Calculate the Concentration of Nitroglycerin in the IV Bag

Concentration (mg/mL) = Total mg of Nitroglycerin / Total mL of Solution

=50 mg / 250 mL

= 0.2 mg/mL

Calculate the Infusion Rate = Infusion Rate (mL/hour)

=0.9 mg/hour / 0.2 mg/mL

= 4.5 mL/hour

Round to the Nearest Whole Number

4.5 mL/hour rounded to 5 mL/hour

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A client, who is 4 hours postoperative laparotomy, has rapidly increasing abdominal distention with elevated pulse and respiratory rates. The client's skin is cool and pale, and there is no change in the blood pressure. Which intervention should the nurse implement immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is completing a neurological assessment on a client with a head injury. The Glasgow Coma Scale (GCS) score is 14. Which intervention should the nurse implement?

Correct Answer is D

Explanation

Correct Answer is ["5"]

Explanation

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