A nurse is caring for a patient who has just returned from the operating room after a major abdominal surgery. The nurse notices that the patient's blood pressure is 90/60 mmHg, pulse is 120 beats/min, respiratory rate is 24 breaths/min, oxygen saturation is 92%, and urine output is 20 mL/h. What is the nurse's priority action?

Administer oxygen via nasal cannula.

Increase the rate of intravenous fluids.

Notify the physician or surgeon.

Administer pain medication.

Answer and Explanation

The Correct Answer is B

A. Administering oxygen may help improve oxygen saturation, but the primary concern is hypotension and tachycardia, which suggest possible hypovolemia.
B. The patient’s vital signs, BP 90/60 mmHg, pulse 120 beats/min, urine output 20 mL/h, indicate early hypovolemic shock. The priority intervention is to increase intravenous fluids to restore circulating volume and perfusion.
C. Notifying the physician is important but should follow initiating immediate interventions to stabilize the patient.
D. Administering pain medication does not address the patient’s hemodynamic instability and is not a priority at this time.

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Correct Answer is B

Explanation

A. "I feel tingling in my fingers and toes.” B. "I have difficulty swallowing and speaking.” C. "I have a dry mouth and increased thirst.” D. "I feel muscle weakness and fatigue."

Correct Answer is A

Explanation

Choice A reason:

Tingling in the fingers and toes is a sign of paresthesia, which is a common symptom of hypocalcemia. Hypocalcemia occurs when the blood calcium level is too low, which can happen after a thyroidectomy if the parathyroid glands are damaged or removed. The parathyroid glands produce parathyroid hormone, which regulates calcium balance in the body. Without enough parathyroid hormone, calcium levels drop and cause neuromuscular irritability and numbness or tingling sensations.

Choice B reason:

Difficulty swallowing and speaking is not a specific sign of hypocalcemia, but rather a possible complication of a thyroidectomy due to injury to the recurrent laryngeal nerve. This nerve innervates the muscles of the larynx, which control voice production and swallowing. Damage to this nerve can cause hoarseness, weak voice, or vocal cord paralysis.

Choice C reason:

Dry mouth and increased thirst are not signs of hypocalcemia, but rather signs of dehydration. Dehydration can occur for various reasons, such as fluid loss, inadequate fluid intake, or increased fluid needs. Dehydration can affect the electrolyte balance in the body, but it does not directly cause hypocalcemia.

Choice D reason:

Muscle weakness and fatigue are not specific signs of hypocalcemia, but rather general signs of malaise. Malaise can occur for various reasons, such as infection, inflammation, stress, or chronic illness. Malaise can affect the physical and mental well-being of a person, but it does not directly cause hypocalcemia.

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is assessing a client who had a thyroidectomy. The nurse suspects that the client is experiencing hypocalcemia due to inadvertent damage to the parathyroid glands. Which of the following statements by the client supports this suspicion?

Correct Answer is A

Explanation

A nurse is teaching a patient about wound care after a minor surgical procedure. Which of the following instructions should the nurse include? (Select all that apply.)

A nurse is changing the dressing of a patient who had a chest surgery two days ago. The nurse observes that the wound edges are separated and there is a small amount of pink serous drainage on the dressing. What should the nurse do?

A nurse is preparing a client for discharge after a mastectomy. The nurse teaches the client how to perform arm exercises to prevent lymphedema and promote mobility. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who had an abdominal hysterectomy. The nurse observes that the client has a low-grade fever, foul-smelling vaginal discharge and lower abdominal tenderness. Which of the following actions should the nurse take first?

A nurse is monitoring a patient's temperature after surgery. The patient has a fever of 38.5°C (101.3°F) and chills. What is the most likely cause of the fever?

A nurse is assessing a patient's pain level after surgery. The patient rates their pain as 8 out of 10 and says it feels like a sharp stabbing pain in the surgical site. What should the nurse say to the patient?

A nurse is reviewing the discharge instructions for a client who had a total hip replacement. Which of the following statements by the client indicate a need for further teaching? (Select all that apply.)