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 ["A","B","E"]
Explanation
Wound infection is a significant risk factor for dehiscence. Infections can weaken the wound edges and delay healing, increasing the likelihood of the wound reopening.
Choice B rationale
Obesity is a risk factor for dehiscence because excess adipose tissue can place additional stress on the wound, impair blood flow, and delay healing.
Choice C rationale
Altered mental status is not directly associated with an increased risk of dehiscence. While it may affect a patient’s ability to follow postoperative care instructions, it is not a primary risk factor.
Choice D rationale
Pain medication administration is not a risk factor for dehiscence. Pain management is essential for recovery and does not contribute to wound reopening.
Choice E rationale
Poor nutritional state is a risk factor for dehiscence because adequate nutrition is essential for wound healing. Malnutrition can impair the body’s ability to repair tissues and increase the risk of wound complications.
Correct Answer is A
Explanation
Choice A rationale
The ability to comply with anticoagulant therapy for life is essential for clients undergoing mechanical valve replacement. Mechanical valves are prone to thrombus formation, which can lead to serious complications such as stroke. Therefore, lifelong anticoagulation therapy is necessary to prevent clot formation on the valve.
Choice B rationale
While body image problems may arise due to surgical scars or the presence of a mechanical valve, they are not a primary concern that needs to be assessed before surgery. The focus should be on the client’s ability to manage the medical requirements post-surgery.
Choice C rationale
The physical demands of the client’s lifestyle are important but not as critical as the ability to comply with anticoagulant therapy. The primary concern is ensuring the client can adhere to the necessary medical regimen to prevent complications.
Choice D rationale
Participation in a cardiac rehabilitation program is beneficial for recovery and improving cardiovascular health, but it is not as crucial as the ability to comply with anticoagulant therapy. The main priority is preventing thrombus formation on the mechanical valve.
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