A nurse is caring for a female client following abdominal surgery.

Select the 2 findings that the nurse should recognize as expected findings.

Abdominal assessment

Hematocrit

Oxygen saturation

Pain assessment

Urinary output

Answer and Explanation

Correct Answer : C,E

A. Abdominal assessment: A distended abdomen with hypoactive bowel sounds on postoperative day 3 is not expected and can suggest developing postoperative ileus. The continued absence of bowel movements and persistent distention indicate delayed return of bowel function and require further assessment.

B. Hematocrit: A hematocrit of 34% on postoperative day 1 is slightly low and reflects postoperative hemodilution or mild blood loss, but it is not an expected finding for postoperative day 3 since no new labs are provided.

C. Oxygen saturation: An oxygen saturation of 97% on room air on postoperative day 3 demonstrates adequate oxygenation and recovery of respiratory function. It indicates that the client is no longer requiring supplemental oxygen, which is expected as mobility improves and anesthetic effects wear off.

D. Pain assessment: Severe pain rated 8–9 out of 10 on postoperative day 3, despite medication, is not expected. Pain should be gradually improving by this time, and uncontrolled pain suggests complications such as infection, ileus, or abscess formation that require further evaluation.

E. Urinary output: A 12-hr urine output of 800 mL reflects normal renal function and adequate hydration. This level of urine production is expected postoperatively, especially with an indwelling catheter in place ensuring accurate measurement.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Weight gain: Weight gain is an expected finding in hypervolemia because excess fluid accumulates in the body, increasing overall body weight. Daily weight monitoring is a key indicator for assessing fluid status in clients at risk for volume overload.

B. Bradycardia: Hypervolemia often increases cardiac workload, which can lead to tachycardia rather than bradycardia. A slow heart rate is not typically associated with fluid overload.

C. Hypotension: Hypervolemia generally causes increased blood pressure due to the expanded intravascular volume. Hypotension is more commonly associated with hypovolemia or fluid loss.

D. Loss of skin turgor: Loss of skin turgor is a sign of dehydration or fluid deficit, not hypervolemia. Clients with fluid overload may have edema, but their skin turgor is usually normal or may appear taut rather than decreased.

A. Respiratory alkalosis B. Hypotension C. Septic shock D. Cardiac arrhythmias E. Renal failure F. Cerebral edema

Correct Answer is ["B","D","E","F"]

Explanation

A. Respiratory alkalosis: The client’s arterial pH is 7.30, indicating acidemia rather than alkalemia. Respiratory alkalosis is not expected in hyperglycemic crises; instead, metabolic acidosis may develop due to ketone accumulation and dehydration.

B. Hypotension: The client’s blood pressure is 96/65 mm Hg, which is lower than normal, likely related to dehydration from osmotic diuresis caused by severe hyperglycemia. Ongoing fluid loss increases the risk of hypotension, making it an important complication to monitor and manage promptly.

C. Septic shock: While the client has a recent history of bronchitis and pneumonia, there is no current evidence of infection such as fever, tachypnea, or elevated WBCs. Although infection could precipitate hyperglycemia, septic shock is not an immediate complication indicated by the current findings.

D. Cardiac arrhythmias: The client has a potassium level of 5.5 mEq/L, which is elevated. Hyperkalemia increases the risk of cardiac arrhythmias, especially in combination with dehydration and acidosis, making close cardiac monitoring necessary.

E. Renal failure: Elevated BUN (21 mg/dL) and creatinine (1.7 mg/dL) suggest impaired renal perfusion or acute kidney injury secondary to dehydration from osmotic diuresis. The client is at risk of progression to renal failure if fluid and electrolyte imbalances are not corrected.

F. Cerebral edema: Cerebral edema is often caused by an overly rapid drop in effective serum osmolarity during treatment, primarily when blood glucose is lowered too quickly. The rapid shift in fluid from the bloodstream to the brain cells can cause swelling.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a female client following abdominal surgery. Select the 2 findings that the nurse should recognize as expected findings.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has hypervolemia, which of the following is an expected assessment finding?

Correct Answer is A

Explanation

A nurse is caring for a client in the emergency department. The nurse is caring for the client in the ED. The nurse understands that the client is at risk of developing which of the following complications? Select all that apply.

Correct Answer is ["B","D","E","F"]

Explanation

A nurse is caring for a client following an esophagogastroduodenoscopy (EGD). Which of the following findings indicate to the nurse that the client can resume oral intake?

A nurse is caring for a female client following abdominal surgery. For each potential action, click to specify if the action is indicated or not indicated for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

A nurse is performing a skin assessment for a client who has been on bed rest for 1 week. The nurse notes reddened areas on the client's scapulae. Which of the following actions should the nurse take?

A nurse finds a client in bed, unresponsive and breathing. Which of the following actions should the nurse take first?

A nurse is caring for a client in the emergency department. Which of the following 3 provider prescriptions does the nurse anticipate?

A nurse is teaching a client who has a new prescription for montelukast to treat asthma. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is teaching a client who has burns to the upper body about positioning to prevent contractures. Which of the following information should the nurse include?

A nurse is caring for a female client following abdominal surgery.

Select the 2 findings that the nurse should recognize as expected findings.