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 B
Explanation
Choice A reason: Elevating the bed to 45° increases bleeding risk at the femoral site post-catheterization; flat positioning is preferred. Assessing pulses is priority. Elevating risks hematoma, critical to avoid in ensuring vascular safety, monitoring for complications, and supporting recovery in immediate postoperative cardiac catheterization care.
Choice B reason: Assessing peripheral pulses every 15 minutes post-femoral catheterization monitors for arterial occlusion or bleeding, critical for detecting complications like hematoma or thrombosis. This ensures timely intervention, essential for vascular integrity, preventing limb ischemia, and supporting safe recovery in the immediate postoperative period.
Choice C reason: Changing the dressing 4 hours post-catheterization is premature unless soiled; initial monitoring of pulses is priority. Assuming dressing change is urgent risks disrupting the site, increasing bleeding, critical to avoid in ensuring site stability and vascular safety in immediate post-catheterization care.
Choice D reason: Flexing the right knee is contraindicated post-femoral catheterization, risking site disruption or bleeding; leg immobility is required. Assessing pulses is key. Instructing flexion risks hematoma, critical to prevent in ensuring vascular safety, monitoring complications, and supporting recovery in postoperative cardiac catheterization clients.
Correct Answer is D
Explanation
Choice A reason: Aspirin is contraindicated in peptic ulcer disease due to its antiplatelet and gastric irritant effects, risking bleeding or ulcer exacerbation. Acetaminophen is safer. Administering aspirin risks gastrointestinal hemorrhage, critical to avoid in ensuring safe pain management for clients with a history of peptic ulcers.
Choice B reason: Ibuprofen, an NSAID, irritates the gastric mucosa, worsening peptic ulcers and increasing bleeding risk, making it unsuitable. Acetaminophen is preferred. Administering ibuprofen risks ulcer perforation or bleeding, critical to prevent in ensuring safe headache relief for clients with a peptic ulcer history.
Choice C reason: Ketorolac, an NSAID, is contraindicated in peptic ulcer disease due to its potent gastric irritant effects, risking ulcer aggravation or bleeding. Acetaminophen is safe. Administering ketorolac risks severe gastrointestinal complications, critical to avoid in providing safe pain management for clients with peptic ulcer history.
Choice D reason: Acetaminophen is safe for headache relief in peptic ulcer clients, lacking gastric irritant effects, avoiding risks of bleeding or ulcer worsening. Administering it ensures effective pain management, critical for client comfort, preventing gastrointestinal complications, and supporting safe care in clients with a history of peptic ulcers.
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