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 D rationale
Positioning the client on the abdomen for 20 to 30 minutes twice a day helps prevent hip flexion contractures. This position stretches the hip flexor muscles, reducing the risk of contractures and promoting better range of motion.
Choice A rationale
Maintaining the client in a supine position does not effectively prevent hip flexion contractures. It is important to vary the client’s position to avoid stiffness and promote mobility.
Choice B rationale
Maintaining a high-Fowler’s position when the client is in bed can increase the risk of hip flexion contractures. This position keeps the hip flexed, which can lead to contractures over time.
Choice C rationale
Elevating the stump on a pillow can help reduce swelling but does not address the prevention of hip flexion contractures. The focus should be on positioning that stretches the hip flexors.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Palpate the area behind the ankle bone. This action is correct. The posterior tibial pulse is located behind the medial malleolus (ankle bone), and palpating this area is necessary to assess the pulse.
Choice B rationale
Use the pads of the fingers to feel for the pulse. This action is correct. Using the pads of the fingers provides a more sensitive and accurate assessment of the pulse compared to using the fingertips or thumb.
Choice C rationale
Compare the pulse strength with the other leg. This action is correct. Comparing the pulse strength bilaterally helps identify any discrepancies that may indicate vascular issues.
Choice D rationale
Assess for any swelling or tenderness. This action is incorrect. While assessing for swelling or tenderness is essential in a general physical examination, it is not a specific step in assessing the posterior tibial pulse.
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