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
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.
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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