A nurse is assessing a client who is 1 hr postoperative following roux-en Y gastric bypass surgery. Which of the following findings is the priority for the nurse to report to the provider?
Client report of back pain of 7 on a 0 to 10 scale
Excoriated folds of the client's panniculus
Hypoactive bowel sounds upon auscultation
urine output of 80 mL in the past hour
The Correct Answer is A
Choice A rationale:
Postoperative pain management is crucial for the client's comfort and recovery.
Choice B rationale:
Excoriated folds of the client's panniculus might be related to skin irritation and can be addressed without immediate provider notification.
Choice C rationale:
Hypoactive bowel sounds can be expected after surgery and might not require immediate reporting.
Choice D rationale:
Urine output of 80 mL in the past hour might be influenced by various factors and is not as high a priority as severe pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Increased thirst is a common manifestation during the dying process due to dehydration and reduced fluid intake.
Choice B rationale:
Decreased secretions can occur as the body's systems gradually shut down during the dying process.
Choice C rationale:
Flushing of the extremities, also known as mottling, can occur due to poor circulation as the body's systems shut down.
Choice D rationale:
Periods of apnea or irregular breathing patterns can occur as the body's respiratory system becomes less effective during the dying process.
Correct Answer is D
Explanation
Choice A rationale:
A blood pressure of 78/60 mm Hg is indicative of hypotension which is a common complication of anorexia nervosa. However. the low body temperature takes precedence
Choice B rationale:
Weight loss of 20% over the last 6 months is concerning but may not be an immediate indicator for acute care admission.
Choice C rationale:
An apical pulse rate of 50/min is bradycardia, which can be a result of anorexia nervosa, but it may not be an immediate indicator for acute care admission unless the client is symptomatic.
Choice D rationale:
A body temperature of 35.5°C (95.9°F) is below a normal range signfyng hypothermia which needs immedate intervention.
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