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
Red skin with edema in the nail beds is more indicative of a superficial injury or inflammation, such as cellulitis or a mild burn, rather than frostbite.
Choice B rationale
Black fingertips surrounded by an erythematous rash suggest gangrene or severe necrosis, which can occur in advanced stages of frostbite but is not an initial finding.
Choice C rationale
A white appearance to the skin that is insensitive to touch is a classic sign of frostbite. The lack of sensation is due to the freezing of tissues and nerves, and the white color indicates a lack of blood flow to the affected area.
Choice D rationale
A pink edematous hand is more indicative of a mild inflammatory response or early stages of frostbite before the tissue has frozen. It does not represent the more severe presentation of frostbite.
Correct Answer is B
Explanation
Choice A rationale
Avoid handwashing after eating. This statement is incorrect. Handwashing is a critical preventive measure to reduce the risk of viral hepatitis, especially after eating or using the restroom.
Choice B rationale
Avoid foods prepared with tap water. This statement is correct. In areas where the water supply may be contaminated, it is essential to avoid foods prepared with tap water to reduce the risk of viral hepatitis, particularly hepatitis A, which can be transmitted through contaminated food and water.
Choice C rationale
Avoid eating meat. This statement is incorrect. While it is essential to ensure that meat is cooked thoroughly to prevent foodborne illnesses, avoiding meat altogether is not a specific preventive measure for viral hepatitis.
Choice D rationale
Avoid covering sores with bandages. This statement is incorrect. Covering sores with bandages can help prevent the spread of infections, including viral hepatitis, by reducing the risk of contact with infectious fluids.
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