A nurse is assessing a client following abdominal surgery. Which of the following findings should the nurse report to the provider?
Urinary output 20 mL/hr
Serous drainage on abdominal dressing
Temperature 37.6° C (99.7° F)
Blood pressure 100/70 mm Hg
The Correct Answer is A
A. Urinary output 20 mL/hr: A urinary output less than 30 mL/hr in an adult indicates potential renal hypoperfusion or urinary retention. This is a priority finding that should be reported to the provider promptly.
B. Serous drainage on abdominal dressing: Serous drainage is a normal postoperative finding, indicating normal wound healing and fluid exudate. It does not require immediate provider notification.
C. Temperature 37.6° C (99.7° F): This temperature is slightly elevated but within the expected postoperative range due to the inflammatory response. It does not indicate an urgent complication.
D. Blood pressure 100/70 mm Hg: This blood pressure is within normal limits for many adults and is not necessarily concerning in a postoperative context unless accompanied by other symptoms such as tachycardia or dizziness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Personalize the conflict: Making a conflict personal can increase tension and defensiveness among staff. Effective negotiation requires addressing issues objectively rather than targeting individuals.
B. Identify solutions prior to negotiation: Preselecting solutions may limit collaborative problem-solving. Effective negotiation involves exploring options with all parties to reach mutually acceptable outcomes.
C. Attempt to understand both sides of the issue: Understanding each party’s perspective promotes open communication, trust, and collaboration. This approach helps identify common ground and develop solutions that are acceptable to all involved.
D. Focus on how the conflict occurred: Concentrating on past events can create blame and hinder forward-focused problem-solving. Effective negotiation emphasizes current needs and potential solutions rather than dwelling on the cause.
Correct Answer is C
Explanation
A. Atrial fibrillation: This dysrhythmia is characterized by an irregularly irregular rhythm with absent or unidentifiable P waves, not a prolonged constant P-R interval.
B. Premature atrial complexes: PACs involve early P waves that may have a normal or slightly different P-R interval, but they do not cause a consistently prolonged P-R interval across all beats.
C. First-degree atrioventricular block: A constant P-R interval greater than 0.20 seconds indicates a first-degree AV block. The atrial impulses are delayed at the AV node, but all impulses are conducted to the ventricles, producing a regular rhythm with prolonged P-R intervals.
D. Complete heart block: In complete heart block (third-degree AV block), there is no relationship between P waves and QRS complexes. The P-R interval is variable, unlike the constant prolongation seen in first-degree AV block.
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