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.

Answer and Explanation

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

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Correct Answer is D

Explanation

According to the Rule of Nines, the percentage of body surface area for different parts of the body is calculated to estimate burn severity. For example, the anterior and posterior aspects of each leg account for 18% each, and the back accounts for 18%. Therefore, the total body surface area burned can be estimated based on these percentages.

A. Fat neck veins. B. Hypotension. C. Poor skin turgor. D. Bradycardia. E. Pale yellow urine.

Correct Answer is ["B","C"]

Explanation

Choice A rationale

Fat neck veins are not a typical finding in a client with frequent vomiting and diarrhea. Dehydration, which is common in such cases, usually leads to flat neck veins due to reduced intravascular volume.

Choice B rationale

Hypotension is a common finding in clients with frequent vomiting and diarrhea due to fluid loss and dehydration. The loss of fluids leads to a decrease in blood volume, resulting in low blood pressure.

Choice C rationale

Poor skin turgor is a classic sign of dehydration, which is expected in clients with frequent vomiting and diarrhea. Dehydration causes the skin to lose its elasticity, leading to poor skin turgor.

Choice D rationale

Bradycardia is not typically associated with dehydration. In fact, dehydration often leads to tachycardia (increased heart rate) as the body tries to compensate for the reduced blood volume.

Choice E rationale

Pale yellow urine is not a typical finding in dehydration. Dehydration usually leads to concentrated urine, which is darker in color. Pale yellow urine indicates adequate hydration.

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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?

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Naxlex Comprehensive Predictor Exams

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