A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
Yellow-green drainage on the surgical incision
Blood pressure 102/66 mm Hg
Straw colored urine from an indwelling urinary catheter
Respiratory rate 18/min
The Correct Answer is A
Yellow-green drainage from a surgical incision may indicate the presence of infection, especially if the drainage is purulent. This finding should be reported to the provider promptly for further evaluation and management to prevent complications such as wound infection or dehiscence.
A. Yellow-green drainage on the surgical incision: Yellow-green drainage suggests the presence of infection, which is a concerning finding in a postoperative client. It may indicate purulent drainage, which requires further assessment and possibly treatment with antibiotics.
B. Blood pressure 102/66 mm Hg: A blood pressure of 102/66 mm Hg is within the normal range for an adult client and does not typically require immediate intervention. However, trends in blood pressure should be monitored, especially if the client is symptomatic or if there are significant changes from the client's baseline.
C. Straw-colored urine from an indwelling urinary catheter: Straw-colored urine is a normal finding and indicates adequate hydration and kidney function. As long as the urine output is adequate and there are no other signs of urinary tract issues, this finding does not typically require immediate reporting.
D. Respiratory rate 18/min: A respiratory rate of 18 breaths per minute is within the normal range for an adult client and does not typically require immediate intervention. However, it's important to assess the client's respiratory status comprehensively, including oxygen saturation and lung sounds, to ensure adequate ventilation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Apply 4 to 5 ml of liquid soap to the hands: This is the correct action. Applying an adequate amount of soap ensures effective cleaning of the hands. The recommended amount is typically 3 to 5 ml or enough to cover the entire surface of the hands.
B. Hold the hands higher than the elbows: This is incorrect. When performing hand hygiene, the hands should be held lower than the elbows to prevent water from running down the arms and contaminating previously cleaned areas.
C. Rub hands and arms to dry: This is incorrect. After washing the hands, they should be dried using a clean paper towel or air dryer. Rubbing hands and arms to dry is not recommended as it can lead to friction and potential skin irritation.
D. Adjust the water temperature to feel hot: This is incorrect. The water temperature should be warm, not hot, to prevent skin damage or discomfort. Hot water can strip the skin of its natural oils and lead to dryness or irritation.
Correct Answer is C
Explanation
To determine the total number of units of insulin to prepare in the insulin syringe, add together the prescribed doses of regular insulin and NPH insulin.
Regular insulin: 14 units NPH insulin: 28 units
Total: 14 units (regular insulin) + 28 units (NPH insulin) = 42 units
Therefore, the nurse should prepare a total of 42 units of insulin in the insulin syringe: 14 units of regular insulin and 28 units of NPH insulin
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