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 D
Explanation
A. Instruct the client to stay in the same position for 2 min: While it is important for the client to remain in a supine position with the head tilted back slightly after instilling nasal decongestant drops, there is no need for the client to remain in the same position for a specific duration such as 2 minutes.
B. Tell the client to blow her nose gently before the instillation: Blowing the nose before instilling nasal decongestant drops is not necessary and may cause irritation to the nasal passages. The drops should be instilled directly into the nasal passages without prior blowing of the nose.
C. Assist the client to a side-lying position: There is no need to assist the client to a side-lying position for the administration of nasal decongestant drops. The drops are typically administered with the client in a seated or supine position with the head tilted back slightly.
D. Hold the dropper 2 cm (1 in) above the nares: This is the correct action. Holding the dropper approximately 2 cm (1 in) above the nares allows for precise instillation of the drops into the nasal passages without touching the dropper to the nares, which helps prevent contamination.
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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