Blog

A client postoperative Day 2, in the last 24 hours, had a urinary output of 900 ml.  The client weighs 65 kg. What is the next best action of the nurse? (Hint: 0.5 ml/kg/hr). 

On admission to the post anesthesia care unit (PACU), the client’s blood pressure was 128/75 mmHg, Heart Rate 80 beats per minute, alert and oriented.  Thirty minutes later, the blood pressure decreases to 82/55 mmHg with a pulse of 125 beats per minute.  The nurse assesses the client drowsy, confused, restless, clammy and diaphoretic skin.  Which intervention should the nurse implement first?

A client’s family history reveals they may be at risk for malignant hyperthermia (MH) during anesthesia. The student nurse asks the nurse if the client’s family history will affect their surgery.  What is the best response from the nurse?

The nurse is assessing the potassium level with a client.  The nurse recognizes a critical complication in both hyperkalemia and hypokalemia is: 

A client with Type 2 Diabetes Mellitus has been well controlled with insulin injections and has been NPO since midnight before having a mastectomy. The client is receiving intravenous fluids with dextrose. The nurse has an order to give insulin per correctional sliding scale.  What is the next best action of the nurse?

The nurse is admitting a 80-year-old client with altered mental status. The family stated the client was nauseous and vomiting before admission. The client is confused and agitated.   What is the next best action of the nurse? 

The client is admitted with a potassium level of 6.5 mEq/L. The client complains of chest palpitations. What does the nurse expect to administer?

The client is admitted for nausea and vomiting. An arterial blood gas (ABG) has been drawn: pH 7.50  CO2 50 and HCO3 34. The nurse interprets the ABG as (Hint: Use the arrows, ROME acronym: Respiratory Opposite, Metabolic Equal): 

The nurse assesses a client postoperative day 4 with a temperature of 101.5 F. The client is on a nasal cannula, has a foley catheter, and a midline abdominal surgical wound.  Before calling the provider, what is a priority assessment of the nurse? 

On admission to the post anesthesia care unit (PACU), the client’s blood pressure was 128/75 mmHg, Heart Rate 80 beats per minute, alert and oriented.  Thirty minutes later, the blood pressure decreases to 82/55 mmHg with a pulse of 125 beats per minute.  The nurse assesses the client drowsy, confused, restless, clammy and diaphoretic skin.  Which intervention should the nurse implement first?