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 D
Explanation
Rationale:
A. The client's frequency of incontinence has decreased: Incontinence is not a direct measure of blood glucose control or the effectiveness of metformin. Changes in urinary frequency may be influenced by other conditions, such as urinary tract infections or prostate issues, and do not indicate the medication’s success.
B. The client's iron level has increased: Metformin does not affect iron metabolism. An increase in iron levels would be unrelated to metformin therapy and could reflect dietary changes, supplementation, or other underlying conditions.
C. The client's high-density lipoprotein level has increased: While metformin may have mild beneficial effects on lipid profiles, its primary purpose is to improve glycemic control. Changes in HDL are not the main indicator of therapeutic success for this medication.
D. The client's HbA1c has decreased: HbA1c reflects average blood glucose levels over the past 2–3 months. A decrease indicates improved glycemic control, which is the primary goal of metformin therapy. Monitoring HbA1c is the most reliable measure to evaluate the effectiveness of the medication.
Correct Answer is B
Explanation
Rationale:
A. Dietary intake: The client ate 75% of breakfast, which indicates adequate oral intake. While monitoring nutrition is important in schizophrenia, this finding does not pose an immediate safety concern or require urgent reporting.
B. Sore throat: A sore throat in a client taking clozapine is significant because clozapine can cause agranulocytosis, a potentially life-threatening reduction in white blood cells. Any signs of infection, such as sore throat or fever, must be reported immediately to prevent serious complications.
C. Heart rate: A heart rate of 98/min is slightly elevated but within acceptable limits for many adults. This finding alone does not indicate an urgent issue requiring immediate provider notification.
D. Blood pressure: A blood pressure of 102/56 mm Hg is slightly low but may be within the client’s normal range, particularly if the client experiences dizziness when changing positions. While it should be monitored, it does not require urgent reporting unless symptoms worsen.
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