Difficulty: Medium
Average Score: 93%
Simulated
Passage / Scenario
The client is a 12-year-old male who sustained a gunshot wound to his abdomen. He had a surgical repair of a perforated small intestine 4 days ago. The client is 112.4 Ib. (51 kg). He has a nasogastric tube, a left femoral central line for fluids, and a right hand peripheral intravenous line.Review H and P, laboratory results, flow sheet, and orders.
The nurse receives the report from the lab and documents the intake and output for 1600.
Based on the client's information at 1600, what symptoms should the nurse look for?
Correct answer
A,D,E,F
Rationale
Post-abdominal surgery with IV fluids, the client is at risk for fluid/electrolyte imbalances, manifesting as edema, dry skin, thirst, and muscle weakness. Irritability, fatigue, and hypertension are less specific in this context.