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

Answer and Explanation

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.

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Correct Answer is A, C, B, D, E

Explanation

A. Open the airway using a jaw-thrust maneuver: The first step in a primary survey is to assess the airway and ensure it is open. The jaw-thrust maneuver is used to open the airway without moving the neck in case of a potential cervical spine injury.

C. Determine effectiveness of ventilator efforts: Once the airway is open, the next step is to assess breathing. This includes observing for chest rise and fall, listening for breath sounds, and feeling for air movement.

B. Establish IV access: After the airway and breathing have been assessed, circulation is the next priority. This includes establishing IV access for fluid and medication administration.

D. Perform a Glasgow Coma Scale assessment: The Glasgow Coma Scale is used to assess the client’s level of consciousness, which is part of the disability assessment in the primary survey.

E. Remove clothing for a thorough assessment: Finally, removing the client’s clothing allows for a thorough assessment of injuries. This is typically done after the immediate life-threatening issues have been addressed.

Correct Answer is ["175"]

Explanation

We are asked to calculate the dosage of cephazolin for a 1-month-old infant based on their weight.

Steps to solve: 1. Identify the given values:

Dose per kg = 50 mg/kg
Weight of the infant = 3500 g

2. Set up the formula: Dosage (mg) = Dose per kg (mg/kg) × Weight (kg)

3. Since the weight is given in grams, convert it to kilograms: 3500 g / 1000 g/kg = 3.5 kg

4. Substitute the known values into the formula and calculate: Dosage (mg) = 50 mg/kg × 3.5 kg Dosage (mg) = 175 mg

5. Round the answer to the nearest tenth: Dosage (mg) = 175.0 mg

The nurse should administer 175.0 mg of cephazolin per dose.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is conducting a primary survey of a client who has sustained life threatening injuries due to a motor vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)

Correct Answer is A, C, B, D, E

Explanation

Correct Answer is ["175"]

Explanation

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