A nurse is assessing a client who is 6 hours postoperative following a total abdominal hysterectomy. Which of the following findings should the nurse report to the provider?

The client has decreased bowel sounds in all four quadrants.

The client’s total urinary output is 75 mL in the last 3 hours.

The client reports a pain level of 4 on a scale of 0 to 10.

The client’s dressing has a scant amount of dark red drainage.

None

Answer and Explanation

The Correct Answer is B

Choice A reason: Decreased bowel sounds 6 hours post-hysterectomy are expected due to anesthesia and surgical manipulation, typically resolving within 24-48 hours. Urinary output of 75 mL in 3 hours is more urgent. Assuming bowel sounds require reporting risks overlooking critical renal issues, potentially delaying intervention in postoperative care.

Choice B reason: Urinary output of 75 mL in 3 hours (25 mL/hour) is below the expected 30-50 mL/hour, indicating potential renal compromise or obstruction post-hysterectomy, requiring immediate reporting. This ensures timely intervention, critical for preventing acute kidney injury, ensuring fluid balance, and supporting recovery in postoperative clients.

Choice C reason: A pain level of 4 is moderate and manageable with routine analgesics, not requiring immediate provider reporting compared to low urinary output. Assuming pain is urgent risks misprioritizing, potentially delaying critical interventions for renal issues, essential for ensuring comprehensive postoperative care and client stability.

Choice D reason: Scant dark red drainage is expected 6 hours post-hysterectomy, indicating minor surgical oozing, not requiring immediate reporting. Low urinary output is priority. Assuming drainage is concerning risks diverting focus from renal complications, critical for preventing kidney injury and ensuring safe recovery in postoperative clients.

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Correct Answer is C

Explanation

Choice A reason: Wrapping sterile gauze for bleeding is inappropriate; gentle pressure and provider notification are needed. Petroleum jelly prevents adhesion. Using gauze risks infection or trauma, critical to avoid in ensuring safe circumcision healing, supporting parental care, and preventing complications in newborns post-procedure.

Choice B reason: Removing yellow exudate, a normal healing sign, risks disrupting the circumcision site, causing pain or infection. Petroleum jelly is correct. Assuming removal is needed risks delayed healing, critical to prevent in ensuring proper wound care and parental education for newborns post-circumcision.

Choice C reason: Applying petroleum jelly to the glans with diaper changes prevents diaper adhesion, promotes healing, and reduces discomfort post-circumcision. This instruction is critical for parental care, ensuring infection prevention, supporting newborn comfort, and facilitating proper healing in the sensitive post-procedure period.

Choice D reason: Using soap on the circumcision site risks irritation and delayed healing; gentle water cleansing is preferred. Petroleum jelly is appropriate. Assuming soap is safe risks discomfort or infection, critical to avoid in ensuring proper care and healing for newborns following circumcision procedures.

A. Provide unleavened bread. B. Provide chicken with a cream sauce. C. Avoid serving fish with fins and scales. D. Avoid serving foods containing lamb.

Correct Answer is A

Explanation

Choice A reason: Unleavened bread (matzah) is required during Passover in Orthodox Judaism, as leavened products are prohibited. Providing it respects dietary laws, critical for cultural sensitivity, ensuring nutritional needs, and supporting client comfort, aligning with patient-centered care principles during religious observances in healthcare settings.

Choice B reason: Chicken with cream sauce is prohibited during Passover, as Orthodox Jews avoid mixing meat and dairy (kosher laws). Unleavened bread is appropriate. Serving this risks dietary violation, causing distress, critical to avoid in ensuring culturally sensitive care for clients observing Passover in healthcare settings.

Choice C reason: Fish with fins and scales is kosher and permitted during Passover, not to be avoided. Unleavened bread aligns with Passover rules. Assuming fish avoidance risks unnecessary restriction, potentially affecting nutrition, critical to prevent in supporting dietary adherence for Orthodox Jewish clients during Passover.

Choice D reason: Lamb is permitted during Passover if kosher, not universally avoided. Unleavened bread is a dietary staple. Assuming lamb avoidance risks misaligned care, potentially causing nutritional or cultural issues, critical to avoid in ensuring respectful, adherent care for Orthodox Jewish clients observing Passover.

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A nurse is assessing a client who is 6 hours postoperative following a total abdominal hysterectomy. Which of the following findings should the nurse report to the provider?

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Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to the parents of a newborn who has been circumcised. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is planning care for a client who practices Orthodox Judaism and is observing the Passover holiday. Which of the following actions should the nurse include in the plan of care?

Correct Answer is A

Explanation

A nurse is assessing a client who is 6 hours postoperative following a total abdominal hysterectomy. Which of the following findings should the nurse report to the provider?

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