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
Explanation
Choice A rationale
Silvery, white scales are a characteristic finding in psoriasis. Psoriasis is a chronic autoimmune condition that causes rapid skin cell turnover, leading to the buildup of scales and red patches on the skin.
Choice B rationale
Intense pain is not typically associated with psoriasis. While psoriasis can cause discomfort and itching, it is not usually described as intensely painful.
Choice C rationale
Unilateral lesions are not characteristic of psoriasis. Psoriasis typically presents with symmetrical lesions on both sides of the body.
Choice D rationale
Serous drainage is not a common finding in psoriasis. Psoriasis lesions are usually dry and scaly rather than exudative. .
Correct Answer is C
Explanation
Choice A rationale
Moist skin is not typically associated with cirrhosis. Cirrhosis often leads to dry, itchy skin due to bile salt accumulation under the skin.
Choice B rationale
Blood in the urine is not a common finding in cirrhosis. This symptom is more indicative of urinary tract issues or kidney problems.
Choice C rationale
Spider angiomas are a common finding in clients with cirrhosis. These are small, dilated blood vessels that appear close to the surface of the skin and are caused by increased estrogen levels due to liver dysfunction.
Choice D rationale
Tarry stools indicate gastrointestinal bleeding, which can occur in cirrhosis due to varices, but it is not a primary expected finding.
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