A nurse is assessing a client who is 48 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
Respiratory rate 18/min.
Blood pressure 102/66 mm Hg.
Yellow-green drainage on the surgical incision.
Straw-colored urine from an indwelling urinary catheter.
The Correct Answer is C
Choice A rationale
A respiratory rate of 18/min is within the normal range for adults and does not typically require immediate intervention.
Choice B rationale
A blood pressure of 102/66 mm Hg is within the normal range for adults and does not typically require immediate intervention.
Choice C rationale
Yellow-green drainage from a surgical incision suggests infection and should be reported to the provider immediately for further evaluation and management.
Choice D rationale
Straw-colored urine from an indwelling urinary catheter is a normal finding and indicates adequate hydration and kidney function
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Serosanguineous drainage is a normal finding at pin sites and does not indicate infection. It is a mixture of serum and blood and is expected during the initial healing phase.
Choice B rationale
Mild erythema around the pin sites can be a normal inflammatory response and does not necessarily indicate infection. It is important to monitor for other signs of infection.
Choice C rationale
Warmth at the pin sites can be a normal finding due to increased blood flow during the healing process. However, it should be monitored in conjunction with other signs of infection.
Choice D rationale
Fever is a systemic sign of infection and indicates that the body is responding to an infectious process. It is a critical finding that requires prompt attention and intervention.
Correct Answer is D
Explanation
Choice A rationale
Loss of appetite is a common symptom of appendicitis due to the inflammation and irritation of the gastrointestinal tract. This symptom alone does not indicate an immediate need for intervention.
Choice B rationale
Nausea and vomiting are also common symptoms of appendicitis. The pain and inflammation can stimulate the vomiting center in the brain, leading to nausea. This symptom, while uncomfortable, does not require immediate intervention.
Choice C rationale
Pain that worsens with movement, such as positioning on the right side, is typical of appendicitis. This is due to the irritation of the peritoneum and the inflamed appendix. This symptom is expected and does not require immediate intervention.
Choice D rationale
The sudden disappearance of pain in a patient with appendicitis can indicate a rupture of the appendix. This is a medical emergency as it can lead to peritonitis, a severe and potentially life- threatening infection of the abdominal cavity. Immediate intervention is required to prevent complications.
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