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
None
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Playing with a jump rope requires advanced coordination, typical of older children, not 30-month-olds, who engage in simpler play like trucks. Assuming jump rope is appropriate risks overestimating development, potentially frustrating the child, critical to avoid in supporting age-appropriate activities for toddlers.
Choice B reason: Playing with a large plastic truck is developmentally appropriate for a 30-month-old, supporting gross motor and imaginative play, critical for cognitive and physical development. This activity aligns with toddler abilities, essential for fostering engagement, creativity, and motor skills in early childhood care settings.
Choice C reason: Imaginary friends typically emerge around 3-4 years, not at 30 months, when simpler play like trucks is common. Assuming imaginary play is expected risks misjudging development, potentially overlooking age-appropriate activities, critical to prevent in supporting toddler engagement and growth.
Choice D reason: Dress-up play is more typical for preschoolers (3-5 years), requiring advanced imagination beyond 30-month-olds, who prefer trucks. Assuming dress-up is appropriate risks developmental mismatch, potentially reducing engagement, critical to avoid in ensuring age-appropriate activities for toddlers in care settings.
Correct Answer is C
Explanation
Choice A reason: Personal blogs are unreliable, lacking evidence-based guidance for diabetes management, risking misinformation. ADA food exchange lists are credible. Providing blogs risks client confusion or harmful practices, critical to avoid in ensuring accurate, safe dietary education for type 2 diabetes mellitus management.
Choice B reason: The Institute of Medicine does not provide specific food label recommendations for diabetes; ADA exchange lists are standard. Assuming IOM resources are appropriate risks inadequate dietary guidance, potentially affecting glycemic control, critical to prevent in supporting effective diabetes self-management at discharge.
Choice C reason: ADA food exchange lists provide evidence-based meal planning, helping clients manage type 2 diabetes through balanced carbohydrate intake. This resource is critical for glycemic control, promoting adherence, ensuring nutritional education, and supporting long-term health, essential for effective diabetes management post-discharge.
Choice D reason: The Physicians’ Desk Reference provides medication details but not dietary guidance, unlike ADA exchange lists for diabetes meal planning. Assuming PDR is sufficient risks neglecting nutritional education, critical to avoid in ensuring comprehensive diabetes self-management and glycemic control at discharge.
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