ExhibitPatient Assessment DataAge12 yearsProcedureTranssphenoidal HypophysectomyPost-operative Time1 hourLevel of ConsciousnessAlert and orientedOxygen Saturation (room air)98%Heart Rate88 bpmBlood Pressure110/68 mmHgRespiratory Rate16 breaths/minTemperature98.6°F (37.0°C)Urine Output (past 1 hour)350 mL (clear, pale yellow)IV FluidsNone ordered (KVO saline lock)The nurse cares for a 12-year-old client one hour post-operative following transsphenoidal hypophysectomy. ➢ After reviewing the assessment findings, the nurse should take which action? Select all that apply. See the exhibit.

notify the health care provider of the urine output.

request an order for intravenous (IV) fluids

continue to monitor neurological status

NCLEX Question: ExhibitPatient Assessment DataAge12 yearsPro

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Child Health

Exhibit

Patient Assessment Data
Age	12 years
Procedure	Transsphenoidal Hypophysectomy
Post-operative Time	1 hour
Level of Consciousness	Alert and oriented
Oxygen Saturation (room air)	98%
Heart Rate	88 bpm
Blood Pressure	110/68 mmHg
Respiratory Rate	16 breaths/min
Temperature	98.6°F (37.0°C)
Urine Output (past 1 hour)	350 mL (clear, pale yellow)
IV Fluids	None ordered (KVO saline lock)

The nurse cares for a 12-year-old client one hour post-operative following transsphenoidal hypophysectomy.

➢ After reviewing the assessment findings, the nurse should take which action? Select all that apply. See the exhibit.

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