The nurse is assessing a client who had valve replacement surgery yesterday. It would be a priority for the nurse to report which assessment finding to the healthcare provider?

Urinary output 275ml over last 8 hours

Hemoglobin 14g/dl (12-16 g/dl)

Heart rate 110 and irregular

Oral temperature 99.2◦FA

Answer and Explanation

The Correct Answer is C

a. Urinary output 275ml over the last 8 hours: While urinary output is an important parameter to monitor, especially in post-operative patients, a urinary output of 275ml over 8 hours is within an acceptable range. It is important to ensure adequate renal perfusion and urine output, but this finding does not raise immediate concerns.

b. Hemoglobin 14g/dl (12-16 g/dl): A hemoglobin level of 14g/dl is within the normal range and does not indicate any immediate issues with oxygen-carrying capacity or blood loss. While it is important to monitor hemoglobin levels post-operatively, this finding does not require immediate action.

c. Heart rate 110 and irregular: A heart rate of 110 beats per minute (bpm) and irregular rhythm is concerning, especially in a post-operative patient who recently underwent valve replacement surgery. An irregular heart rate could indicate cardiac dysrhythmias, which may be related to the surgery or underlying cardiac issues. This finding warrants further evaluation and may require intervention, making it a priority for the nurse to report to the healthcare provider.

d. Oral temperature 99.2°F: An oral temperature of 99.2°F is slightly elevated but is not significantly outside the normal range. While fever can indicate infection, post-operative patients can have mild elevations in temperature due to the inflammatory response to surgery. Unless accompanied by other signs of infection or instability, this finding may not be a priority for immediate reporting.

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Correct Answer is A

Explanation

a. Metabolic alkalosis: Metabolic alkalosis can occur due to loss of gastric acid through suctioning of gastric contents via the nasogastric tube. Continuous suctioning of gastric contents can lead to loss of hydrogen ions (H+) and chloride ions (Cl-) from the stomach, resulting in metabolic alkalosis.

b. Metabolic acidosis: Metabolic acidosis is less likely in this scenario unless there are other factors contributing to acidosis, such as renal dysfunction or excessive administration of certain medications. Suctioning of gastric contents would lead to loss of acid, which could potentially predispose the client to metabolic alkalosis rather than metabolic acidosis.

c. Respiratory alkalosis: Respiratory alkalosis is less likely to occur in this scenario. Although the client is NPO and may be experiencing some respiratory compensation due to metabolic alkalosis, the primary acid-base disturbance would be metabolic rather than respiratory.

d. Respiratory acidosis: Respiratory acidosis is not typically associated with suctioning of gastric contents. Instead, it occurs due to inadequate alveolar ventilation, leading to retention of carbon dioxide (CO2) and subsequent respiratory acidosis. This imbalance is more commonly seen in conditions such as respiratory depression, neuromuscular disorders, or airway obstruction.

A. Abdominal distension B. Digoxin level 4.1 ng/ml (0.8-2.0ng/ml) C. Blurry vision D. Increased platelet level E. Arrhythmia

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

Explanation

a. Abdominal distension: Abdominal distension can occur in cases of severe digoxin toxicity due to its effects on gastrointestinal motility. Digoxin toxicity can lead to nausea, vomiting, and abdominal discomfort, which can contribute to abdominal distension. Therefore, abdominal distension is consistent with digoxin toxicity.

b. Digoxin level 4.1 ng/ml (0.8-2.0ng/ml): Digoxin levels above the therapeutic range (0.8-2.0 ng/ml) indicate digoxin toxicity. A level of 4.1 ng/ml is significantly higher than the therapeutic range, confirming digoxin toxicity.

c. Blurry vision: Blurry vision is a common symptom of digoxin toxicity. Visual disturbances, such as yellow or green halos around lights or changes in color vision, can occur due to digoxin's effects on the optic nerve. Therefore, blurry vision is consistent with digoxin toxicity.

d. Increased platelet level: Digoxin toxicity typically does not cause an increase in platelet levels. Instead, it can lead to thrombocytopenia (a decrease in platelet levels) due to its effects on bone marrow function. Therefore, increased platelet levels are not consistent with digoxin toxicity.

e. Arrhythmia: Digoxin toxicity can cause various cardiac arrhythmias, including atrial tachycardia, atrioventricular block, and ventricular tachycardia. Therefore, experiencing arrhythmias is consistent with digoxin toxicity.

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The nurse is assessing a client who had valve replacement surgery yesterday. It would be a priority for the nurse to report which assessment finding to the healthcare provider?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is post-operative following a bowel resection. The client is NPO with a nasogastric tube connected to suction. Which acid base imbalance is this client at risk to develop?

Correct Answer is A

Explanation

The nurse is caring for a client with digoxin toxicity. Which findings are consistent with this diagnosis? Select all that apply.

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

Explanation

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