The nurse is assessing a client in the post-anesthesia care unit. The client's vital signs are T 98°F, P 106, R 24, and BP 88/40. The client is awake and oriented x 3 and the skin is pale and damp. The client denies complaints of pain. What intervention should the nurse implement first?

Start an IV of DSNS with 40 mEq KCI at 125 mL/hr

Elevate the feet and lower the head

Call the surgeon and report the vital signs

Monitor the vital signs every 15 minutes

Answer and Explanation

The Correct Answer is B

A. Start an IV of DSNS with 40 mEq KCI at 125 mL/hr: Starting an IV is important but may not be the immediate first step. The client's symptoms suggest hypotension, likely due to hypovolemia, which needs immediate positional intervention before fluid administration.
B. Elevate the feet and lower the head: This position, known as the Trendelenburg position, helps increase venous return to the heart and can quickly improve blood pressure and perfusion to vital organs. It is an immediate intervention for hypotension.
C. Call the surgeon and report the vital signs: While important, calling the surgeon is not the first intervention. Immediate action to stabilize the client's condition is necessary before notifying the healthcare provider.
D. Monitor the vital signs every 15 minutes: Monitoring is important, but it is not an immediate intervention. The nurse must first address the client's low blood pressure and symptoms of hypoperfusion before continuing regular monitoring.

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Correct Answer is B

Explanation

A. 5-hour urine output total of 300 mL: This urine output is low, but it may not immediately indicate a serious issue without additional context. However, monitoring for adequate urine output is important.
B. Serum potassium level of 3.0 mEq/L: This is the correct choice. A serum potassium level of 3.0 mEq/L indicates hypokalemia, a serious side effect of furosemide, which can lead to cardiac arrhythmias and requires immediate intervention.
C. Current blood pressure of 141/80 mm Hg: Although the blood pressure is still elevated, it is not as urgent as correcting hypokalemia. The medication’s effectiveness should be monitored, but it is not an immediate concern.
D. Serum glucose level of 135 mg/dL: This level is slightly elevated but not critically high, and it does not require immediate action related to furosemide use.

A. Decrease the TPN rate to 60 ml/hr B. Replace TPN infusion with an intravenous dextrose solution C. Begin infusion of 0.9% normal saline at 30 ml/hr D. Discontinue TPN infusion E. Discontinue TPN infusion

Correct Answer is B

Explanation

A. Decrease the TPN rate to 60 ml/hr: Gradually decreasing the TPN rate is a common practice, but it is typically done in conjunction with transitioning to another form of nutrition, not as a standalone order.
B. Replace TPN infusion with an intravenous dextrose solution: This is the correct choice. When weaning off TPN, it is important to prevent hypoglycemia by replacing the TPN with a dextrose solution to maintain blood glucose levels while transitioning to oral or enteral feeding.
C. Begin infusion of 0.9% normal saline at 30 ml/hr: While saline may be used for hydration, it does not address the need to manage blood glucose levels during the transition from TPN.
D. Discontinue TPN infusion: Discontinuing TPN abruptly can lead to complications such as hypoglycemia. It is important to gradually taper off TPN while replacing it with a dextrose solution.

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The nurse is assessing a client in the post-anesthesia care unit. The client's vital signs are T 98°F, P 106, R 24, and BP 88/40. The client is awake and oriented x 3 and the skin is pale and damp. The client denies complaints of pain. What intervention should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

Orders were written for a client to be weaned off of total parenteral nutrition (TPN) and started on a low-residue diet. The TPN solution has been infusing at a continuous rate of 90 ml/hr for three weeks. Which of the following orders should the nurse anticipate next?

Correct Answer is B

Explanation

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

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?

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)

The nurse is reviewing serum laboratory values for a client who is scheduled for surgery tomorrow. Which value requires the nurse to promptly notify the surgeon?

A nurse is preparing the skin of a client scheduled for cardiac surgery. What is the purpose of surgical skin cleaning preparation?

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?