A nurse is caring for a client who just returned to the unit after a laparoscopic cholecystectomy. Which of the following findings requires immediate intervention?
Pain in the right shoulder
Small serosanguinous drainage on the dressing
Nausea with a small amount of emesis
Respiratory rate of 10 breaths per minute
The Correct Answer is D
Choice A reason: Right shoulder pain is a common and expected finding after laparoscopic procedures due to residual gas. It does not require immediate intervention unless severe or persistent.
Choice B reason: Small amounts of serosanguinous drainage are normal postoperatively and do not indicate a complication unless excessive or foul-smelling.
Choice C reason: Mild nausea and emesis are common after anesthesia and can be managed with antiemetics. It does not require urgent intervention unless persistent or accompanied by other symptoms.
Choice D reason: A respiratory rate of 10 breaths per minute is below the normal range and may indicate respiratory depression, especially if the client received opioids. This requires immediate assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Furosemide is a loop diuretic that increases the excretion of sodium, potassium, and water. It is more commonly associated with hypokalemia and hyponatremia, not hyperkalemia.
Choice B reason: Hydrochlorothiazide is a thiazide diuretic that can cause hyponatremia and hypokalemia due to its action on the distal tubule, but it does not typically cause hyperkalemia.
Choice C reason: Spironolactone is a potassium-sparing diuretic that blocks aldosterone, leading to sodium excretion and potassium retention. This mechanism increases the risk of hyperkalemia. Additionally, it can contribute to hyponatremia due to water retention and sodium loss.
Choice D reason: Bumetanide, like furosemide, is a loop diuretic and is associated with hypokalemia and hyponatremia, not hyperkalemia.
Correct Answer is B
Explanation
Choice A reason: Holding insulin during illness can lead to hyperglycemia and diabetic ketoacidosis (DKA). Insulin should generally be continued unless otherwise directed.
Choice B reason: Illness increases metabolic stress and can cause unpredictable glucose fluctuations. Frequent monitoring helps detect and manage hyperglycemia or hypoglycemia early.
Choice C reason: Reducing glucose checks during illness is unsafe and increases the risk of complications.
Choice D reason: Checking protein levels is not part of standard sick day management for diabetes. Monitoring ketones and glucose is more relevant.
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