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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Monitor intake and output every shift: Important for tracking fluid balance and ensuring appropriate hydration and nutritional support.
B. Change the IV tubing every seven (7) days: IV tubing should generally be changed every 24 to 72 hours or as per hospital protocol, not every seven days.
C. Place the solution on an IV pump at the prescribed rate: Ensures accurate administration of TPN and prevents complications associated with over or under-infusion.
D. Monitor blood glucose every one (1) hour: Frequent monitoring is required as TPN can cause fluctuations in blood glucose levels.
E. Weigh the client weekly, first thing in the morning: While weighing the client is important, it is typically done more frequently than weekly to monitor fluid status and nutritional response.
Correct Answer is ["A","C","D"]
Explanation
A. Record intake and output: This task is within the UAP's scope of practice as it involves documenting fluid balance.
B. Assess bowel sounds: This task requires clinical judgment and assessment skills and should be performed by a licensed nurse.
C. Obtain routine vital signs: This is appropriate for the UAP to perform, as it involves routine measurements that do not require clinical assessment.
D. Document the presence of edema: The UAP can document observable findings such as edema, which is within their scope of practice.
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