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A nurse is assigned a group of postoperative clients

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A nurse is assigned a group of postoperative clients. Which of the following client findings should the nurse identify as the priority?

 

a. SaO2 88%

b. Client report of incisional pain at a level of 6 on a 0 to 10 scale

c. Infiltration of clients IV access

d. Temperature 36.1*C (97.0*F)

 

A nurse is assessing a client who has asthma and signs of central cyanosis. Which of the following is a reliable indicator of cyanosis?

 

a. Oral mucosa

b. Tip of the nose

c. Ear lobes

d. Eye lids

 

A nurse is monitoring a client who is 12 hr postoperative following a colectomy. Which of the following findings should the nurse report to the provider?

 

a. Bowel sounds 10/min

b. Serum potassium 3.7 g/dL

c. Urine output 48 ml/2 hr

d. Heart rate 90/min

 

A nurse reviewing the laboratory of a client who had a total thyroidectomy discovers that his calcium is 7mg/dL. Which of the following client findings should the nurse expect?

 

a. Muscle tetany

b. Hypertension

c. Increased thirst

d. Diaphoresis

 

A nurse is collecting data from a client who fell at home and reported a brief of loss of consciousness. Which of the following findings should the nurse immediately report to the charge nurse?

 

a. Edematous bruise on forehead

b. Small drops of clear fluid in left ear

c. Client disoriented tp place

d. Heart rate 110/ min and regular