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 ["2"]

Explanation

Here's how we can find the desired flow rate:

Total volume to infuse (in minutes):
- We need to convert the infusion time from hours to minutes.
- Time (minutes) = Time (hours) x 60 minutes/hour
- Time (minutes) = 2 hours x 60 minutes/hour
- Time (minutes) = 120 minutes
Total volume to infuse (in mL):
- Given volume = 250 mL
Drop factor (gtts/mL):
- Given drop factor = 15 gtts/mL
Flow rate (gtts/minute):
- Flow rate = Total volume (mL) / Time (minutes) x Drop factor (gtts/mL)
- Flow rate = 250 mL / 120 minutes x 15 gtts/mL

To simplify the calculation, we can divide all values by 5 (as long as we perform the division on both sides of the equation, the answer won't change):

Flow rate = (250 mL / 5) / (120 minutes / 5) x (15 gtts/mL / 5)
Flow rate = 50 mL / 24 minutes x 3 gtts/mL
Flow rate = 2.0833... gtts/minute (round to nearest whole number)

Rounded flow rate (gtts/minute):
- Flow rate = 2 gtts/minute

Therefore, the nurse should adjust the flow rate to deliver approximately 2 gtts/minute.

A. "Have you talked to your parents about this yet?" B. "Why do you think you are so anxious?" C. "It sounds like you are having a difficult time." D. "How long has this been going on?"

Correct Answer is C

Explanation

A. Asking the client if they have talked to their parents about their anxiety may not be appropriate, as it assumes the client is comfortable discussing their concerns with their parents. It's important to establish rapport and trust with the client before delving into personal matters such as family dynamics.
B. Asking "Why do you think you are so anxious?" may come across as confrontational and put the client on the defensive. It's important to approach the client's concerns with empathy and understanding rather than seeking an explanation for their anxiety.
C. This response acknowledges the client's feelings and validates their experience, showing empathy and understanding. It opens the door for further exploration of the client's concerns and allows the nurse to provide support and assistance.
D. While assessing the duration of symptoms is important, asking "How long has this been going on?" as an initial response may feel dismissive to the client's current distress. Starting with an empathetic acknowledgment of the client's experience can help build rapport and trust before delving into more specific questions about the duration and severity of symptoms.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["2"]

Explanation

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Correct Answer is C

Explanation

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