A nurse is caring for a client who is 2 hr postoperative following an inguinal hernia repair. Which of the following findings should the nurse report to the provider?

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Question 1 of 5

A nurse is caring for a client who is 2 hr postoperative following an inguinal hernia repair. Which of the following findings should the nurse report to the provider?

Correct Answer: D

Rationale: A low urine output of 20 mL/hr, less than the expected 30 mL/hr or more, could indicate renal impairment or inadequate fluid status postoperatively. In this scenario, early detection and intervention are crucial to prevent further complications. The other findings - heart rate of 88/min, pain rating of 4, and blood pressure of 110/70 mm Hg - are within normal limits for a client 2 hr postoperative following an inguinal hernia repair and do not raise immediate concerns.

Question 2 of 5

A nurse is caring for a client who has heart failure and is receiving furosemide. Which of the following findings should the nurse identify as an adverse effect of the medication?

Correct Answer: C

Rationale: The correct answer is C: 'Hypokalemia.' Furosemide is a loop diuretic that can lead to potassium depletion (hypokalemia) due to increased urinary excretion of potassium. This can result in adverse effects such as muscle weakness, cardiac dysrhythmias, and other complications. Hyperkalemia (choice A) is not an adverse effect of furosemide but rather an elevated potassium level. Hyperglycemia (choice B) and hyponatremia (choice D) are not typically associated with furosemide use. Therefore, monitoring potassium levels and addressing hypokalemia is crucial in clients taking furosemide.

Question 3 of 5

A nurse is reviewing the medical record of a client who has major depressive disorder and is taking tranylcypromine. Which of the following foods should the nurse instruct the client to avoid?

Correct Answer: D

Rationale: The correct answer is D: Cured meats. Cured meats contain tyramine, which can lead to a hypertensive crisis in clients taking tranylcypromine. Bananas, milk, and yogurt do not contain significant amounts of tyramine and are safe for clients taking this medication. Therefore, the nurse should instruct the client to avoid cured meats to prevent adverse effects.

Question 4 of 5

A nurse is caring for a client who is 1 day postoperative following an open reduction and internal fixation of the right tibia. Which of the following findings should the nurse report to the provider?

Correct Answer: D

Rationale: Pallor of the affected extremity could indicate impaired circulation, such as compromised blood flow to the area, which is crucial to monitor postoperatively. This finding suggests potential vascular compromise or decreased blood supply to the extremity, which is a serious concern and should be reported promptly to the provider for further evaluation and intervention. Serous drainage on the dressing is a normal finding in the immediate postoperative period and does not necessarily indicate a complication requiring immediate provider notification. Capillary refill of 2 seconds is within the normal range (less than 3 seconds) and indicates adequate peripheral perfusion. A heart rate of 88/min is also within the normal range for an adult and is not typically a cause for immediate concern postoperatively.

Question 5 of 5

A nurse is reviewing the medical record of a client who has chronic kidney disease. The client's potassium level is 6.5 mEq/L. Which of the following actions should the nurse take?

Correct Answer: B

Rationale: The correct answer is B: Administer sodium polystyrene sulfonate. Sodium polystyrene sulfonate is used to treat hyperkalemia by promoting the excretion of potassium. Choice A, administering sodium bicarbonate, is incorrect as it is not used to treat hyperkalemia. Choice C, administering calcium gluconate, is incorrect as it is used to treat hypocalcemia, not hyperkalemia. Choice D, administering calcium carbonate, is incorrect as it is used to treat conditions like osteoporosis and indigestion, not hyperkalemia.

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