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
Rationale:
A. "This medication can cause back pain.": Back pain is not a common or expected adverse effect of warfarin. Teaching should focus on bleeding risks and precautions rather than unrelated symptoms.
B. "Avoid taking this medication with milk products.": Milk does not significantly affect warfarin absorption. The main dietary consideration is maintaining consistent vitamin K intake, as large fluctuations can alter anticoagulation.
C. "Use an electric razor when shaving while taking this medication.": Warfarin increases the risk of bleeding and bruising. Using an electric razor reduces the chance of cuts, promoting safety during routine grooming.
D. "Avoid prolonged exposure to sunlight while taking this medication.": Sun exposure is not contraindicated with warfarin; there is no significant interaction between warfarin and UV light.
Correct Answer is A
Explanation
Rationale:
A. Check the cords of the IV pump for fraying: Inspecting electrical cords for fraying or damage is an important safety step before use. Damaged cords can cause electrical shock, fire hazards, or equipment malfunction, so this helps ensure safe operation.
B. Remove the safety inspection sticker before plugging in the IV pump: Safety inspection stickers indicate that the device has passed electrical and functional safety checks. Removing them would eliminate visible proof of inspection and is not necessary for safe use.
C. Ensure that the electric outlet has two prongs for the IV pump: Medical equipment such as IV pumps should be plugged into grounded three-prong outlets to reduce the risk of electrical shock. Two-prong outlets do not provide this grounding protection.
D. Grasp the IV pump cord when unplugging it from the electrical outlet: Pulling on the cord can damage the internal wires and increase the risk of electrical hazards. The correct method is to grasp the plug itself when disconnecting from the outlet.
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