A nurse is assessing a client 12 hours following an emergency abdominal surgery. Which assessment finding requires prompt collaboration with the primary health care provider?

Abdomen soft, surgical dressing has scant amount of old drainage

Client ambulating with minimal assistance, complaints of occasional nausea

Crackles bilaterally in bases of lungs, has incisional pain

Temperature 99.4°F (37.4°C), pulse 100 bpm, bowel sounds present

Answer and Explanation

The Correct Answer is C

A. Abdomen soft, surgical dressing has scant amount of old drainage: A soft abdomen and minimal old drainage from the surgical dressing are expected findings postoperatively. They do not indicate an immediate concern that requires prompt action.
B. Client ambulating with minimal assistance, complaints of occasional nausea: Ambulation and occasional nausea are common and generally expected postoperatively. These findings do not require urgent collaboration with the healthcare provider.
C. Crackles bilaterally in bases of lungs, has incisional pain: Crackles in the lungs can indicate fluid accumulation or atelectasis, which may lead to pneumonia or other respiratory complications. This finding, especially combined with recent surgery, requires prompt evaluation and intervention.
D. Temperature 99.4°F (37.4°C), pulse 100 bpm, bowel sounds present: A slightly elevated temperature and increased pulse are common after surgery. The presence of bowel sounds is a positive sign indicating the return of gastrointestinal function. These findings are not immediately concerning.

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Correct Answer is A

Explanation

A. Hypocalcemia: Hypocalcemia can cause signs such as muscle twitching, spasms, or tetany, which could be observed in the upper extremity and might be noted during a blood pressure measurement.
B. Hypokalemia: While hypokalemia can cause muscle weakness and cramping, it is less directly associated with specific upper extremity signs compared to hypocalcemia.
C. Hypophosphatemia: This generally affects energy levels and muscle function but is less commonly associated with immediate and visible upper extremity signs.
D. Hyponatremia: This primarily affects fluid balance and mental status, and is less likely to present with specific upper extremity findings during a blood pressure check.

A. Infiltration B. Phlebitis C. Extravasation D. Infection E. - E. Limited ambulation

Correct Answer is B

Explanation

A. Infiltration: Infiltration occurs when IV fluid or medication leaks into the surrounding tissue, typically causing swelling and coolness, but not usually a cord-like vein or a reddened streak.
B. Phlebitis: This is the correct choice. Phlebitis is inflammation of the vein, evidenced by tenderness, burning, swelling, and a reddened streak along the vein. The cord-like vein indicates inflammation.
C. Extravasation: Extravasation involves the leakage of vesicant drugs into surrounding tissue, which can cause severe tissue damage, but usually involves more than just a cord-like vein and reddened streak.
D. Infection: Infection typically presents with more systemic signs like fever and could involve purulent discharge, which is not described in this scenario.

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A nurse is assessing a client 12 hours following an emergency abdominal surgery. Which assessment finding requires prompt collaboration with the primary health care provider?

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Naxlex Comprehensive Predictor Exams

The illustration reflects a client's upper extremity while the nurse obtains a manual blood pressure. Which electrolyte abnormality is the nurse most likely to see in the client's blood chemistry results?

Correct Answer is A

Explanation

After having an intravenous (IV) line in place for 72 hours, a client complains of tenderness, burning, and swelling. Assessment of the IV site reveals a cord-like vein and a reddened streak. The nurse identifies that these findings indicate what complication?

Correct Answer is B

Explanation

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