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. Documenting communication with a provider in the progress notes of the client's medical record: Proper documentation of provider communication is standard nursing practice and does not constitute malpractice. It helps ensure continuity of care and legal protection.
B. Placing a yellow bracelet on a client who is at risk for falls: Implementing fall precautions, such as using a yellow wristband, is an appropriate safety measure and standard of care, not malpractice.
C. Administering potassium via IV bolus: Administering potassium as a rapid IV push is extremely dangerous and can cause cardiac arrest. This action violates the standard of care and constitutes malpractice due to potential harm to the client.
D. Leaving a nasogastric tube clamped after administering oral medication: A nasogastric (NG) tube is often clamped for a short period after administering medication to allow the medication to be absorbed. The nurse's action would only be considered negligent if they left the tube clamped for a prolonged period.
Correct Answer is B
Explanation
A. Give an antibiotic 30 min before dialysis: Some antibiotics may require timing adjustments around dialysis, but this depends on the specific drug and provider orders. Administering antibiotics is not universally required before each dialysis session.
B. Check the vascular access site for bleeding after dialysis: Monitoring the vascular access site for bleeding, swelling, or infection is a critical safety measure after hemodialysis. Proper assessment helps prevent complications such as hemorrhage or thrombosis.
C. Rehydrate with dextrose 5% in water for orthostatic hypotension: Fluid administration during or after dialysis must be carefully managed due to the risk of fluid overload. Standard rehydration with dextrose 5% in water is not routinely recommended for hypotension after dialysis.
D. Withhold all medications until after dialysis: Not all medications should be withheld; some are given before or during dialysis depending on their pharmacokinetics and dialysis clearance. Blanket withholding of medications can be unsafe and may lead to untreated conditions.
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