A nurse is assessing a client 3 days following a hysterectomy. Which of the following findings should the nurse identify as an indication the client is developing a complication?
Increased hemoglobin
Increased urinary output
Unilateral leg swelling
Mild pain at the surgical site
The Correct Answer is C
Rationale:
A. Increased hemoglobin: A rise in hemoglobin is not expected after surgery but also does not suggest a postoperative complication. It may reflect hemoconcentration from mild dehydration or fluid shifts. This finding does not indicate infection, thrombosis, or impaired healing, so it is not a priority concern at this stage.
B. Increased urinary output: Higher urinary output may occur if the client is well-hydrated or receiving IV fluids. This finding does not suggest renal impairment or postoperative complications. As long as urine is clear and the client is stable, increased output is not concerning and requires only routine monitoring.
C. Unilateral leg swelling: One-sided leg swelling is a hallmark sign of deep vein thrombosis, a serious complication after pelvic surgery due to venous stasis and immobilization. A DVT can progress to pulmonary embolism, posing immediate danger. The finding requires prompt evaluation and intervention to prevent life-threatening complications.
D. Mild pain at the surgical site: Mild incisional pain is expected on postoperative day three as tissues heal and inflammation decreases. This finding is typical and manageable with analgesics. As long as pain is not severe or accompanied by fever, redness, or purulent drainage, it does not indicate a complication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. A newborn who has forceful vomiting with feedings: Forceful vomiting in a newborn may indicate pyloric stenosis, gastrointestinal obstruction, or other serious conditions that can quickly lead to dehydration and electrolyte imbalance. This is an urgent finding requiring immediate assessment to prevent rapid deterioration.
B. A newborn who has a heart rate of 160/min while crying: A heart rate of 160/min is within the expected range for a newborn (120–160/min) during activity or crying. While monitoring is necessary, this finding is not immediately concerning and does not require urgent intervention.
C. A newborn who is 24 hr of age and has blood-tinged vaginal discharge: A small amount of blood-tinged vaginal discharge (pseudomenstruation) is a normal hormonal response in female newborns due to maternal estrogen withdrawal. This is an expected finding and does not require urgent assessment.
D. A newborn who is 12 hr of age and has not voided: While monitoring urinary output is important, a newborn may normally not void within the first 12 hours of life. Assessment is needed, but it is not as urgent as forceful vomiting, which can quickly cause serious complications.
Correct Answer is A
Explanation
Rationale:
A. Cheese: Aged and fermented cheeses contain high levels of tyramine, which can interact with MAOIs and cause a hypertensive crisis. Clients taking MAOIs must avoid foods rich in tyramine to prevent sudden and dangerous increases in blood pressure. This dietary restriction is a critical safety consideration when prescribing these medications.
B. Eggs: Eggs are low in tyramine and do not interact with MAOIs. They are safe to consume and provide a good source of protein for clients on this medication. No dietary restrictions are required regarding eggs.
C. Potatoes: Potatoes are low in tyramine and do not pose a risk for hypertensive crisis when taken with MAOIs. They can be included safely in the diet of clients receiving this medication.
D. Grapefruit: Grapefruit interacts with certain medications by affecting CYP450 metabolism, but it does not contain significant tyramine and is not contraindicated with MAOIs. While clients may need to avoid grapefruit with other drugs, it is not a concern specifically for MAOI therapy.
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