The nurse is caring for a client who is 24 hours postoperative ...

[nautica902]

The nurse is caring for a client who is 24 hours postoperative cholecystectomy. The client has a meperidine (Demerol) PCA pump. Which symptom should be reported to the physician immediately?
 
  1. Constipation
  2. Respiratory rate of 18 breaths per minute
  3. Urine output of 15 ml per hour
  4. Urine output of 35 ml per hour

Question 2

The nurse is providing care for a client who is taking acetaminophen (Tylenol). What should the nurse pay particular attention to during the assessment?
 
  1. Respiratory rate
  2. Pulse rate
  3. Blood pressure
  4. Severe upper or lower abdominal pain

[T4T]

Answer to Question 1

Correct Answer: 3

Rationale 1: Constipation does not need to be reported immediately.
Rationale 2: Respiratory rate of 18 breaths per minute is a normal respiratory rate for an adult.
Rationale 3: Renal status and urinary output should be monitored. The nurse should report a scanty urine output.
Rationale 4: Urine output of 35 ml per hour can be a normal output for an adult.

Global Rationale: Renal status and urinary output should be monitored. The nurse should report a scanty urine output. Constipation does not need to be reported immediately. Respiratory rate of 18 breaths per minute is a normal respiratory rate for an adult. Urine output of 35 ml per hour can be a normal output for an adult.

Answer to Question 2

Correct Answer: 4

Rationale 1: Acetaminophen does not change respiratory rate.
Rationale 2: Acetaminophen does not change pulse.
Rationale 3: Acetaminophen does not change blood pressure.
Rationale 4: Clients on acetaminophen (Tylenol) should report signs of liver toxicity, nausea, vomiting, anorexia, bleeding, severe upper or lower abdominal pain, heartburn, jaundice, or a change in the color or character of stools.

Global Rationale: Clients on acetaminophen (Tylenol) should report signs of liver toxicity, nausea, vomiting, anorexia, bleeding, severe upper or lower abdominal pain, heartburn, jaundice, or a change in the color or character of stools. Acetaminophen does not change respiratory rate. Acetaminophen does not change pulse. Acetaminophen does not change blood pressure.

[nautica902]

Gracias!

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TYSM