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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. "I will increase my fluid and fiber intake while I am taking iron tablets.": This statement is correct as increasing fluid and fiber can help manage constipation, a common side effect of iron supplementation.
B. "I will take the tablets with water an hour before eating.": This is correct because taking iron supplements on an empty stomach can improve absorption, and water helps dissolve the tablets.
C. "I will immediately call my health care provider if my stools turn green.": This statement indicates a misunderstanding, as green stools are a common and harmless side effect of iron supplements. They are not typically a cause for concern unless accompanied by other symptoms.
D. "I will take a stool softener if I occasionally feel constipated.": This is a correct and appropriate approach, as stool softeners can help alleviate constipation caused by iron supplements.

A. Respiratory rate 24/min B. Blood pressure 138/86 mm Hg C. Total urinary output 700 mL in 24 hours D. Weight loss of 4 lb in 24 hours

Correct Answer is D

Explanation

A. Respiratory rate 24/min: A respiratory rate of 24/min indicates tachypnea, which can be a sign of ongoing fluid volume excess or other complications. This does not show effective treatment.
B. Blood pressure 138/86 mm Hg: While this blood pressure is within the higher range of normal, it does not specifically indicate effective treatment of fluid volume excess. Blood pressure alone is not a reliable indicator of fluid status.
C. Total urinary output 700 mL in 24 hours: A urinary output of 700 mL in 24 hours is below the normal range (typically 800-2000 mL per day) and suggests that the fluid volume excess has not been effectively treated. Adequate urinary output is a key indicator of effective fluid management.
D. Weight loss of 4 lb in 24 hours: A weight loss of 4 lb in 24 hours is a clear indicator that the client has lost excess fluid, which is the desired outcome in treating fluid volume excess. This demonstrates that the treatment has been effective in reducing fluid retention

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is educating a client on the use of oral ferrous sulfate. Which statement made by the client requires a need for further education?

Correct Answer is C

Explanation

The nurse is caring for a client being treated for fluid volume excess. Which assessment finding indicates that treatment has been effective?

Correct Answer is D

Explanation

A home health nurse is assessing a client receiving TPN infusion for malabsorption after extensive bowel surgery. What finding is most important for the nurse to report to the health care provider?

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?

A nurse is providing care for a hospitalized client admitted with dehydration. Which assessment finding indicates interventions have been effective?

A client is scheduled for surgery at 0800 and has been NPO (nothing by mouth) since midnight. They have been taking long-term oral steroids and are scheduled for their routine dose of Prednisone 30 mg PO to be administered at 0600. Which nursing action is most appropriate?

After having an intravenous (IV) line in place for 72 hours, a client complains of tenderness, burning, and swelling. Assessment of the IV site reveals a cord-like vein and a reddened streak. The nurse identifies that these findings indicate what complication?

Which of the following assessment findings should alert the nurse that a client's IV has infiltrated? (Select All That Apply)

A client with peripheral neuropathy states, "I don't know why the doctor put me on an antidepressant. I am not depressed!" Which response by the nurse is best?

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