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","D","E"]
Explanation
A. Clubbing of the fingers: Clubbing of the fingers is a common finding in clients with advanced emphysema. It is characterized by bulbous enlargement of the fingertips and nail changes, including increased curvature and softening of the nail beds. Clubbing results from chronic hypoxia and tissue oxygen deprivation, which leads to vascular changes and tissue proliferation in the fingertips.
B. Deep respirations: Deep respirations are not typically associated with emphysema. Instead, clients with emphysema often exhibit shallow, rapid respirations due to decreased lung elasticity and air trapping, which impair effective ventilation. As a compensatory mechanism, clients may adopt a pursed-lip breathing pattern to facilitate expiration and reduce airway collapse.
C. Bradycardia: Bradycardia is not a characteristic finding in clients with emphysema. Instead, clients with emphysema commonly experience tachycardia, which is a compensatory response to hypoxia and increased work of breathing. Tachycardia helps maintain cardiac output and tissue perfusion in the setting of impaired gas exchange.
D. Barrel chest: Barrel chest is a classic physical finding in clients with emphysema. It results from hyperinflation of the lungs and loss of lung elasticity, leading to a permanent increase in the anteroposterior diameter of the chest. This change in chest shape contributes to the characteristic appearance of a rounded, barrel-like chest.
E. Dyspnea: Dyspnea, or shortness of breath, is a hallmark symptom of emphysema. Clients with emphysema often experience dyspnea, especially with exertion, due to air trapping, decreased lung function, and impaired gas exchange. Dyspnea can significantly impact the client's quality of life and functional status, requiring careful management and symptom relief interventions.
Correct Answer is ["A","C","D","E"]
Explanation
A. Rotavirus (RV): Rotavirus vaccine is routinely recommended for infants to protect against rotavirus infection, which can cause severe diarrhea and dehydration in young children. It is typically administered orally in multiple doses starting at around 2 months of age.
B. Human papillomavirus (HPV): The HPV vaccine is not routinely administered to infants at 1 year of age. It is typically recommended for preteens and adolescents to protect against HPV-related cancers and genital warts.
C. Measles, mumps rubella (MMR): The MMR vaccine is routinely given to infants around 1 year of age to protect against measles, mumps, and rubella (German measles). It is typically administered as a single injection.
D. Varicella (VAR): The varicella vaccine is routinely recommended for infants to protect against chickenpox (varicella) infection. It is typically administered as a single injection around 1 year of age.
E. Diphtheria, tetanus and acellular pertussis (DTaP): The DTaP vaccine is routinely given to infants to protect against diphtheria, tetanus, and pertussis (whooping cough). It is typically administered as a series of injections starting at around 2 months of age.
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