The nurse has reviewed the Nurses' Notes and Provider Prescriptions at 1100 and Diagnostic Results on Day 3.

A nurse is assisting with the evaluation of the client following surgery. Which of the following findings indicate that the client is experiencing a potential complication of surgery that requires immediate follow-up?

Click to highlight the finding that requires immediate follow-up. To deselect a finding, click on the finding again.

Area assessed

Findings

Neurological

Drowsy but easy to arouse.

Vital Signs

Temperature 35.3° C (95.5° F)

Heart rate 60/min

Respiratory rate 16/min

Blood pressure 90/60 mm Hg

Oxygen saturation 94% (oxygen at 2 L/min via nasal cannula)

Rates pain as 1 on 0/10 pain scale.

Integumentary

Skin cool and moist to touch.

Drowsy but easy to arouse

Temperature 35.3° C (95.5° F)

Heart rate 60/min

Blood pressure 90/60 mm Hg

Rates pain as 1 on 0/10 pain scale

Skin cool and moist to touch

Answer and Explanation

The Correct Answer is ["B","C","D","F"]

The client underwent surgical intervention (right salpingostomy), which carries risks such as hemorrhage, hypovolemic shock, infection, and adverse anesthetic effects. Postoperative assessment findings must be carefully evaluated for early signs of deterioration. Hypotension combined with bradycardia, hypothermia, and cool clammy skin suggests potential shock or significant hemodynamic instability, which requires urgent intervention to prevent cardiovascular collapse.

Rationale for correct choices:

• Blood pressure 90/60 mm Hg: A blood pressure of 90/60 mm Hg indicates hypotension, which is a major postoperative warning sign for possible hemorrhage or shock following ectopic pregnancy surgery. Given the vascular nature of reproductive structures and recent surgical intervention, internal bleeding is a significant concern. This drop in perfusion pressure can rapidly progress to organ hypoperfusion and cardiovascular collapse if not addressed immediately. It is the most urgent abnormal finding requiring immediate follow-up.

• Heart rate 60/min: Bradycardia in the postoperative setting may indicate worsening hemodynamic instability, especially when combined with hypotension. While opioids or anesthesia may contribute, the presence of low blood pressure makes this finding more concerning for circulatory compromise. It may represent a late or atypical response in shock states where compensatory mechanisms are failing. Continuous is essential.

• Temperature 35.3° C (95.5° F): Hypothermia after surgery may result from anesthesia effects, environmental exposure in the operating room, or impaired thermoregulation. However, in combination with hypotension and bradycardia, it may indicate poor perfusion and early shock. Reduced core temperature can impair coagulation, increasing the risk of postoperative bleeding. This finding supports the concern for systemic instability rather than isolated temperature variation.

• Skin cool and moist to touch: Cool, moist skin is a classic sign of peripheral vasoconstriction and sympathetic activation seen in shock states. It reflects the body’s attempt to preserve blood flow to vital organs at the expense of peripheral circulation. When combined with hypotension, it strongly suggests decreased tissue perfusion. This finding supports the likelihood of postoperative hemorrhage or circulatory compromise requiring immediate intervention.

Rationale for incorrect findings:

• Pain rating 1/10: A pain score of 1/10 is an expected and reassuring postoperative finding following laparoscopic surgery. It indicates effective pain control and no evidence of acute complications such as severe internal bleeding or peritoneal irritation. In postoperative monitoring, significant worsening pain would be more concerning for complications. Therefore, a low pain score is a normal and non-alarming finding in this scenario.

• Neurological status: drowsy but easy to arouse: Mild drowsiness is common after anesthesia and opioid administration in the postoperative period. The client is easily arousable and responsive. This suggests intact airway protection and no immediate neurological emergency. In the absence of worsening confusion or unresponsiveness, this finding is expected and not the priority concern.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Albuterol is a short-acting beta-2 adrenergic agonist commonly prescribed for conditions such as bronchitis and asthma to relieve bronchospasm. It works by relaxing smooth muscle in the bronchial walls, leading to bronchodilation and improved airflow. Patient education focuses on understanding its rapid onset of action, correct inhaler use, and expected therapeutic effects. It does not treat infection or directly affect mucus production.

Rationale:
A. Albuterol does not cause drowsiness; instead, it may cause CNS stimulation leading to nervousness, tremors, or insomnia. Sedation is not an expected or therapeutic effect of this medication. Therefore, this statement is incorrect and may indicate confusion about side effects.

B. Waiting 10 seconds between inhalations is not the correct instruction for albuterol administration. The recommended practice is typically to wait about 1 minute between puffs to allow adequate dispersion and absorption of the first dose. However, the key therapeutic effect is still bronchodilation, not timing alone.

C. Albuterol works by stimulating beta-2 receptors in the lungs, resulting in relaxation of bronchial smooth muscle and widening of the airways. This improves airflow and reduces symptoms such as wheezing and shortness of breath in conditions like Bronchitis. This statement correctly describes the medication’s primary therapeutic action.

D. Albuterol does not thin mucus secretions; it has no mucolytic properties. Medications that thin mucus, such as guaifenesin, work through a different mechanism. Confusing bronchodilation with mucus thinning reflects a misunderstanding of the drug’s action.

A. "I'll give my child the iron through a straw." B. "I'll give my child the iron with milk." C. "I'll notify the provider if my child becomes nauseated." D. "I'll notify the provider if my child's stools are tarry."

Correct Answer is A

Explanation

Administration of liquid iron supplements such as Ferrous sulfate in children requires specific teaching to improve absorption and reduce adverse effects. Iron is commonly prescribed for iron deficiency anemia and is best absorbed in an acidic environment, but it can cause staining of teeth and gastrointestinal irritation. Proper administration techniques help improve adherence while minimizing side effects and cosmetic concerns.

Rationale:
A. Giving liquid iron through a straw is appropriate because it helps minimize contact with the teeth and reduces the risk of permanent tooth staining. Ferrous sulfate can discolor enamel, so using a straw and brushing teeth afterward are recommended strategies. This demonstrates correct understanding of safe administration techniques.

B. Giving iron with milk is incorrect because calcium in milk interferes with iron absorption in the gastrointestinal tract. Dairy products bind to iron and reduce its bioavailability, making treatment less effective. Iron should be given with water or vitamin C-rich fluids instead.

C. Mild nausea is a common side effect of iron supplementation and does not require notifying the provider. Gastrointestinal discomfort can often be managed by giving the medication with food (if tolerated) or adjusting timing. Only severe or persistent symptoms would warrant provider notification.

D. Tarry stools are an expected and harmless side effect of oral iron therapy due to unabsorbed iron in the gastrointestinal tract. This change in stool color does not indicate bleeding when the client is taking iron supplements. Parents should be reassured that this is a normal finding.

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Area assessed	Findings
Neurological	Drowsy but easy to arouse.
Vital Signs	Temperature 35.3° C (95.5° F) Heart rate 60/min Respiratory rate 16/min Blood pressure 90/60 mm Hg Oxygen saturation 94% (oxygen at 2 L/min via nasal cannula) Rates pain as 1 on 0/10 pain scale.
Integumentary	Skin cool and moist to touch.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing discharge teaching to a client who has bronchitis, about a prescription for albuterol. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with the guardian of a child who has a new prescription for liquid ferrous sulfate. Which of the following statements by the guardian indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?

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