The nurse is assessing a 60-year-old client who is 6 hours postoperative from colon resection surgery. Immediate postoperative vital signs were BP 126/78 mmHg, HR 80 bpm, RR 13, and Temp 98.9°F. Current vital signs are BP 105/60 mm Hg, HR 120 bpm, RR 21, and Temp 99.1°F. His skin is pale and cool, and his total urine output is 125 mL over 6 hours. What nursing action is most appropriate?

Continue monitoring the client.

Increase nasal oxygen flow rate to 8 L

Place the client in high Fowler's position.

Notify the surgeon as soon as possible

Answer and Explanation

The Correct Answer is D

A. Continue monitoring the client: The client's vital signs, pale and cool skin, and low urine output suggest potential hypovolemic shock or other serious postoperative complications, requiring more immediate intervention than just continued monitoring.
B. Increase nasal oxygen flow rate to 8 L: While increasing oxygen may be necessary, the primary concern is the underlying cause of the client's symptoms, which may require more immediate intervention.
C. Place the client in high Fowler's position: This position may be beneficial for certain conditions but does not address the underlying issues suggested by the vital signs and physical findings.
D. Notify the surgeon as soon as possible: This is the correct choice. The client's hypotension, tachycardia, pale and cool skin, and low urine output indicate potential complications that need immediate evaluation by the surgeon.

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Free Nursing Study Resources

Correct Answer is ["A","B"]

Explanation

A. Potassium 2.9 mEq/L: This indicates hypokalemia, which is a common electrolyte imbalance associated with diuretic therapy, particularly with loop diuretics.
B. Sodium 125 mEq/L: This indicates hyponatremia, another possible electrolyte imbalance resulting from diuretic use.
C. Potassium 4.6 mEq/L: This is within the normal range and does not indicate an imbalance.
D. Sodium 139 mEq/L: This is within the normal range and does not indicate an imbalance.
E. Magnesium 2.1 mEq/L: This is within the normal range and does not indicate an imbalance.

A. Neuromuscular blockers B. Inhaled general anesthesia C. Intravenous general anesthesia D. Regional anesthesia

Correct Answer is D

Explanation

A. Neuromuscular blockers: These are used to induce paralysis and do not affect consciousness or maintain reflexes such as the gag reflex.
B. Inhaled general anesthesia: Generally, inhaled general anesthesia suppresses all reflexes, including the gag reflex.
C. Intravenous general anesthesia: This type of anesthesia typically induces a loss of consciousness and suppression of reflexes, including the gag reflex.
D. Regional anesthesia: This type of anesthesia blocks sensation in a specific area of the body while the client remains conscious and retains reflexes, including the gag reflex.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing serum laboratory test results of a client receiving diuretic therapy. The nurse determines the client is at risk for electrolyte imbalance based on which result(s)? (Select all that apply)

Correct Answer is ["A","B"]

Explanation

The nurse is educating a group of student nurses about the different types of anesthesia. The student demonstrates an understanding of the teaching when they state that a client would maintain a gag reflex with what anesthesia?

Correct Answer is D

Explanation

A client with uncontrolled diabetes mellitus develops metabolic acidosis. Which assessment finding related to the imbalance indicates that the client's compensatory mechanisms are working?

A nurse working in the post-anesthesia care unit (PACU) is caring for a post-operative client that just had pelvic surgery. The nurse anticipates assessing for what post-operative complaint related to spinal anesthesia?

Which client response best supports the decision to discharge the client from the Post-Anesthesia Care Unit?

The client is NPO and is receiving total parenteral nutrition (TPN) via a peripherally inserted central catheter. Which precautions should the nurse implement? (Select All That Apply)

A client is experiencing respiratory depression, constipation, nausea and vomiting, and hypotension after receiving pain medication. Which class of analgesics did this client most likely receive?

A nurse cares for a client with a serum potassium of 5.4 mEq/L. The nurse should anticipate a prescription order for what medication?