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
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.
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