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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Splitting behavior: Splitting, or viewing people as all good or all bad, is characteristic of borderline personality disorder rather than histrionic personality disorder. It reflects difficulty integrating positive and negative aspects of self and others.

B. Emotional lability: Clients with histrionic personality disorder often display rapidly shifting emotions, exaggerated expression of feelings, and attention-seeking behaviors. Emotional lability is a hallmark feature, making this an expected manifestation.

C. Self-centered behavior: While clients with histrionic personality disorder may seek attention, overt self-centeredness and grandiosity are more characteristic of narcissistic personality disorder rather than histrionic traits.

D. Suspicious of others: Suspiciousness and distrust are typical of paranoid personality disorder. Clients with histrionic personality disorder are generally sociable and seek approval rather than displaying pervasive mistrust.

A. Place the head of the client's bed flat with the client's legs extended. B. Apply butterfly strips to approximate the wound edges. C. Apply pressure directly to the wound for 15 min. D. Place a sterile, saline-soaked dressing on the wound.

Correct Answer is D

Explanation

Rationale:

A. Place the head of the client's bed flat with the client's legs extended: Positioning flat may increase tension on the abdominal incision, potentially worsening the dehiscence. A low Fowler’s position with knees slightly bent is preferred to reduce strain on the wound.

B. Apply butterfly strips to approximate the wound edges: Forcing the wound edges together could trap bacteria inside and increase the risk of infection. Dehiscence requires moist protection, not forced closure at the bedside.

C. Apply pressure directly to the wound for 15 min: Direct pressure is appropriate for active bleeding, not for dehiscence. Applying pressure could damage tissues further and does not address the need to protect exposed structures.

D. Place a sterile, saline-soaked dressing on the wound: A moist sterile dressing protects the wound from contamination, prevents the tissues from drying, and reduces the risk of infection while awaiting further surgical evaluation.

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A nurse is assessing a client following abdominal surgery. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has histrionic personality disorder. Which of the following manifestations should the nurse expect?

Correct Answer is B

Explanation

A nurse caring for a postoperative client removes the client's dressing and notes an area of dehiscence. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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