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 ["A","B","C","D"]
Explanation
Choice A reason: Potential complications must be explained before consent to ensure the client understands risks like bleeding or infection, supporting informed decision-making. This is legally required, critical for ethical care, preventing misunderstandings, and ensuring the client is fully aware of colon resection’s potential adverse outcomes before signing.
Choice B reason: Possible alternative treatments, like medication or less invasive procedures, must be discussed to ensure informed consent, allowing the client to weigh options. This is essential for autonomy, critical for ethical practice, ensuring clients understand all viable paths before agreeing to a colon resection procedure.
Choice C reason: An explanation of the procedure, including what a colon resection entails, is required for informed consent, ensuring the client understands the surgical process. This promotes transparency, critical for legal and ethical standards, enabling informed decisions and reducing anxiety before signing the consent form.
Choice D reason: Expected outcomes, such as symptom relief or recovery timeline, must be provided to clarify the procedure’s benefits, ensuring informed consent. This is crucial for setting realistic expectations, supporting client autonomy, and ensuring understanding of colon resection’s purpose, critical for ethical surgical consent processes.
Choice E reason: Cost of the procedure is not typically required for informed consent, which focuses on medical risks, benefits, and alternatives. Assuming cost is necessary risks diverting focus from clinical information, potentially overwhelming the client, critical to avoid in ensuring informed consent for colon resection surgery.
Correct Answer is D
Explanation
Choice A reason: Pork is prohibited in Islam (haram), and including it during Ramadan violates dietary laws, disrespecting the client’s faith. Scheduling meals after sundown respects fasting. Offering pork risks cultural insensitivity, potentially causing distress, critical to avoid in ensuring respectful, patient-centered care during Ramadan.
Choice B reason: Avoiding red meat is not a Ramadan or Islamic requirement; Muslims may consume halal red meat after sundown. Scheduling meals post-sundown is key. Assuming red meat avoidance risks unnecessary dietary restriction, potentially affecting nutrition, critical to prevent in supporting client health during fasting periods.
Choice C reason: Waiting 1 hour after dairy to serve poultry is not an Islamic dietary rule; it may reflect kosher practices. Scheduling meals after sundown aligns with Ramadan fasting. This assumption risks cultural confusion, delaying meals, critical to avoid in ensuring timely nutrition for Muslim clients during Ramadan.
Choice D reason: Scheduling meals after sundown respects Ramadan fasting, when Muslims eat during non-daylight hours (iftar). This ensures nutritional needs are met, critical for health, maintaining cultural sensitivity, and supporting client comfort, aligning with patient-centered care principles for devout Muslims observing Ramadan in healthcare settings.
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