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. Respiratory acidosis without compensation: The pH of 7.22 indicates acidosis, but the HCO3 level of 23 mEq/L suggests that compensation is occurring because the HCO3 is within the normal range for respiratory acidosis.
B. Metabolic acidosis with full compensation: The high PaCO2 level is more indicative of respiratory issues, not metabolic acidosis. Additionally, compensation for metabolic acidosis would show elevated HCO3.
C. Respiratory acidosis with partial compensation: The elevated PaCO2 and low pH indicate respiratory acidosis. The normal HCO3 level suggests partial compensation by the kidneys.
D. Metabolic acidosis without compensation: The elevated PaCO2 and normal HCO3 suggest respiratory acidosis rather than metabolic acidosis.

A. Calcium B. Selenium C. Potassium D. Bicarbonate

Correct Answer is C

Explanation

A. Calcium: Thiazide diuretics can increase calcium levels, but the primary concern is the potential loss of potassium.
B. Selenium: This is not directly related to thiazide diuretic therapy and does not address the primary electrolyte imbalance.
C. Potassium: This is the correct choice. Thiazide diuretics can cause hypokalemia (low potassium levels). Encouraging potassium-rich foods helps to counteract this side effect.
D. Bicarbonate: While bicarbonate can be important for acid-base balance, it is not the primary concern with thiazide diuretics, which typically affect potassium levels.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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?

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?

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?

A hospitalized client is receiving IV furosemide (Lasix) to treat stage 2 hypertension. Which assessment finding related to the medication requires prompt collaboration with the health care provider?

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 working on a medical surgical unit is assigned four clients at the start of their shift. What client should be given the highest priority?

The nurse is providing teaching to the client about the use of vitamins and supplements. The nurse would state that vitamin D has a major role in which process?