A nurse is monitoring a client who is 12 hr postoperative following a colectomy. Which of the following findings should the nurse report to the provider?
Heart rate 90/min
Serum potassium 3.7 g/dL
Bowel sounds 10/min
Urine output 48 m/2 hr
The Correct Answer is D
a. Heart rate 90/min: A heart rate of 90/min is within the normal range, and it is not an abnormal finding postoperatively.
b. Serum potassium 3.7 g/dL: The serum potassium level of 3.7 g/dL is within the normal range, and it is not an abnormal finding postoperatively.
c. Bowel sounds 10/min: Bowel sounds of 10/min are within the normal range and indicate return of bowel function postoperatively.
d. Urine output 48 m/2 hr: A urine output of 48 m/2 hr is less than the expected urine output (30 mL/hr), and it may indicate inadequate renal perfusion or function. This finding should be
reported to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Restrict oral fluids to 800 to 1,000 mL/day: Hyponatremia is a characteristic finding in SIADH, and fluid restriction is a key intervention to correct the imbalance.
b. Maintain an IV of 0.45% sodium chloride: Infusing hypertonic (3%) saline may be indicated in severe cases of hyponatremia, but the initial step is fluid restriction.
c. Ensure the client receives a 2 g/day sodium diet: Dietary sodium restriction is not the primary intervention for SIADH. Fluid restriction is more critical.
d. Administer desmopressin acetate 0.2 mg orally: Desmopressin acetate is an antidiuretic
hormone and would exacerbate the retention of water, further decreasing sodium levels. It is not the appropriate intervention for this client.
Correct Answer is A
Explanation
a. Increasing dyspnea: Atelectasis is the collapse of alveoli, leading to decreased lung volume and impaired gas exchange. Dyspnea (difficulty breathing) is a common symptom as the lung's ability to oxygenate the blood is compromised.
b. Dry cough: A dry cough may be present, but it is not specific to atelectasis. It can occur for various reasons postoperatively.
c. Facial flushing: Facial flushing is not a typical finding in atelectasis. It is more commonly associated with conditions such as fever or allergic reactions.
d. Decreasing respiratory rate: Atelectasis can lead to increased respiratory rate as the body tries to compensate for decreased lung function. A decreasing respiratory rate would be less likely in the presence of atelectasis.
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