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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Correct Answer is C

Explanation

A. Client's serum pH is 7.41: This is within the normal range for blood pH (7.35-7.45) and does not specifically indicate a potassium deficit.
B. Client has a stage 2 sacral wound: This is related to skin integrity and does not directly impact potassium levels.
C. Client requires continuous nasogastric suction: Continuous nasogastric suction can lead to the loss of potassium as it removes gastric contents, which may include electrolytes.
D. Client has a history of adrenal insufficiency: While adrenal insufficiency can affect electrolyte balance, continuous nasogastric suction is a more immediate risk for potassium deficit.

A. Level of consciousness B. Condition of drains C. Appearance of the surgical dressing D. Stability of vital signs

Correct Answer is D

Explanation

A. Level of consciousness: While important, it follows the assessment of vital signs to ensure the client's overall stability.
B. Condition of drains: This is relevant but not as immediate as assessing the stability of vital signs.
C. Appearance of the surgical dressing: This is important but secondary to ensuring the client’s vital signs are stable.
D. Stability of vital signs: This is the most critical next assessment after ensuring a patent airway, as vital signs reflect the client's immediate physiological status and stability.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to care for a client with an electrolyte imbalance. After reviewing the electronic health record, what finding should the nurse understand places that client at the greatest risk for developing a potassium deficit?

Correct Answer is C

Explanation

After ensuring a postoperative client has a patent airway, what is the next most important nursing assessment?

Correct Answer is D

Explanation

A client indicates to the nurse a pain level of 8 out of 10. The nurse notes the client has an order for morphine 4 mg IV Q 6 hr PRN for moderate to severe pain. The client's blood pressure is 80/54 mm Hg, respirations 10 breaths/min, and pulse 62 beats/min. Which action should the nurse take?

The pharmacy just delivered the sustained-release opioid tablets newly prescribed for a client with a gastrostomy tube. What should the nurse do when preparing to provide this medication to the client?

The nurse is providing care for several clients at risk for acid-base imbalance. Which client has the greatest risk for respiratory acidosis?

An unresponsive client was brought to the emergency room and had an arterial blood gas drawn. Ten minutes later, the laboratory calls with the following results: PaO2 74%, pH 7.22, PaCO2 85 mm Hg, and HCO3 23 mEq/L. The nurse interprets the results as indicating which imbalance?

Which menu choice indicates that a client understands their nurse's teaching about the best dietary sources of iron?

A client with leukemia is expected to require chemotherapy for several months. Which type of IV line will best meet the client's needs?

A client has been receiving IV potassium therapy. Upon further assessment, the nurse notes the site has become erythematous and edematous. Which action by the nurse is most appropriate?

The nurse is taking a medication history of a client scheduled for surgery the next morning. Which medication requires the nurse to immediately notify the surgeon?