A nurse is assessing a client following abdominal surgery. Which of the following findings should the nurse report to the provider?
Temperature 37.6°C (99.7°F).
Serous drainage on abdominal dressing.
Urinary output 20 mL/hr.
Blood pressure 100/70 mm Hg.
The Correct Answer is C
Choice A reason: A temperature of 37.6°C is normal post-surgery, not requiring reporting; low urinary output is urgent. Assuming temperature is concerning risks overlooking renal issues, potentially delaying intervention, critical to avoid in ensuring comprehensive postoperative monitoring and client safety after abdominal surgery.
Choice B reason: Serous drainage is expected post-abdominal surgery, indicating normal healing, not requiring reporting. Low urinary output is priority. Assuming drainage is urgent risks misprioritizing, potentially neglecting renal complications, critical to prevent in ensuring proper postoperative care and recovery in surgical clients.
Choice C reason: Urinary output of 20 mL/hr is below normal (30-50 mL/hr), indicating potential renal impairment or dehydration post-surgery, requiring immediate reporting. This ensures timely intervention, critical for preventing kidney injury, maintaining fluid balance, and supporting recovery in clients post-abdominal surgery.
Choice D reason: Blood pressure of 100/70 mm Hg is low but not critical unless symptomatic; low urinary output is more urgent. Assuming blood pressure requires reporting risks overlooking renal issues, critical to avoid in ensuring prioritized monitoring and intervention in postoperative abdominal surgery clients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Swimming is contraindicated with a fiberglass cast, as water exposure risks skin irritation or cast damage. A hair dryer relieves itching. Allowing swimming risks infection or cast breakdown, critical to avoid in ensuring proper healing and parental education for children with arm casts.
Choice B reason: Positioning the arm in a sling at bedtime is unnecessary; elevation on pillows promotes circulation. A hair dryer addresses itching. Assuming a sling is required risks discomfort, critical to prevent in ensuring proper cast care and comfort for children post-fracture.
Choice C reason: Using a hair dryer on a cool setting safely relieves itching under a fiberglass cast, preventing skin irritation from scratching. This instruction is critical for comfort, ensuring proper cast care, supporting healing, and educating parents on safe management of a child’s arm cast post-injury.
Choice D reason: Checking finger movement every 6 hours is insufficient; frequent checks (e.g., every 2-4 hours) ensure circulation. A hair dryer is correct for itching. Assuming 6-hour checks risks delayed detection of complications, critical to avoid in ensuring safe cast care for children with fractures.
Correct Answer is A
Explanation
Choice A reason: A speech-language pathologist assesses swallowing difficulties, recommending safe feeding techniques for dysphagia, critical for preventing choking and aspiration in older adults. This referral ensures tailored interventions, essential for nutritional safety, reducing pneumonia risk, and supporting quality of life in long-term care settings.
Choice B reason: Occupational therapists address functional skills, not primarily swallowing, which is managed by speech-language pathologists for dysphagia. Assuming their role risks delayed swallowing assessment, potentially increasing choking risk, critical to avoid in ensuring safe eating for older adults in long-term care facilities.
Choice C reason: Respiratory therapists manage breathing issues, not swallowing difficulties, which require a speech-language pathologist for dysphagia. Assuming their involvement risks missing specialized swallowing care, potentially leading to aspiration, critical to prevent in ensuring safe nutrition for older adults with choking risks.
Choice D reason: Social workers address psychosocial needs, not swallowing issues, managed by speech-language pathologists for dysphagia. Assuming their role risks neglecting physical swallowing assessment, increasing choking or aspiration risk, critical to avoid in ensuring safe meal management for older adults in long-term care.
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