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 C
Explanation
Choice A rationale
A mesh-like device within the catheter that springs open is characteristic of a stent, not a balloon-tipped catheter used in PTCA. Stents are often used in conjunction with angioplasty to keep the artery open after the balloon has compressed the plaque.
Choice B rationale
While catheters can be used to take pressure measurements, this is not the primary function of the balloon-tipped catheter in PTCA. The main purpose of the balloon-tipped catheter is to compress the plaque against the artery wall to improve blood flow.
Choice C rationale
The balloon-tipped catheter in PTCA is used to compress the plaque against the coronary blood vessel wall. This process, known as balloon angioplasty, helps to widen the artery and improve blood flow to the heart.
Choice D rationale
Cutting away plaque with an embedded blade is a description of atherectomy, not PTCA. Atherectomy involves a different type of catheter designed to remove plaque from the artery wall.
Correct Answer is C
Explanation
Choice A rationale
Inserting a nasogastric (NG) tube is not the first priority in managing a client with gastrointestinal bleeding. The primary concern is to stabilize the client and assess their condition. Inserting an NG tube can be considered later to decompress the stomach and assess the extent of bleeding, but it is not the initial step.
Choice B rationale
Asking the client about the precipitating events is important for gathering information, but it is not the first priority. The immediate focus should be on assessing the client’s current condition and stabilizing them. Once the client is stable, a detailed history can be obtained.
Choice C rationale
Obtaining vital signs is the first priority in managing a client with gastrointestinal bleeding. Vital signs provide critical information about the client’s hemodynamic status and help determine the severity of the bleeding. This information is essential for guiding further interventions and ensuring the client’s stability.
Choice D rationale
Completing a head-to-toe assessment is important, but it is not the first priority. The initial focus should be on assessing the client’s vital signs to determine their hemodynamic status. A comprehensive assessment can be performed once the client’s immediate condition is stabilized.
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