The nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client’s vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next?

Correct Answer: D

Rationale: Notify the nursing manager. The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status, therefore the next action is to activate the chain of command to ensure the client receives care.

Correct Answer: D

Rationale: Abdominal cramping. Low sodium level manifests as cramping, weakness, confusion, and lethargy. Chvostek’s sign is a manifestation of hypomagnesemia and hypocalcemia. Tachycardia is a manifestation of hyponatremia along with hypovolemia.

Correct Answer: C

Rationale: It might help me to listen to music while I’m lying in bed.

Correct Answer: A

Rationale: The first step in addressing reported constipation is to assess the client’s condition. An abdominal assessment (e.g., checking for distension, bowel sounds, or tenderness) provides critical data to determine the cause and severity of constipation, guiding subsequent interventions. Evaluating fluid intake (B) is important but follows assessment to identify contributing factors. Requesting Colace (C, a stool softener) or walking (D, to stimulate peristalsis) are interventions that require baseline data from an assessment to justify and prioritize.

Correct Answer: A

Rationale: 750 mL ÷ 8 hr = 93.75 mL/hr, rounded to 94 mL/hr.