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 B

Explanation

Choice A reason: Protective eyewear is not required for MRI; removing transdermal patches prevents burns. Assuming eyewear is needed risks misinformation, potentially causing confusion, critical to avoid in ensuring accurate preparation and safety for clients undergoing MRI scans in diagnostic settings.

Choice B reason: Removing transdermal patches before an MRI prevents burns from metallic components, critical for client safety. This instruction ensures proper preparation, reducing injury risk, supporting safe imaging, and adhering to MRI safety protocols, essential for clients undergoing magnetic resonance imaging procedures.

Choice C reason: Tattoos are generally safe for MRI, though rare risks exist; patches are a greater concern. Assuming tattoos contraindicate MRI risks unnecessary restriction, potentially delaying diagnosis, critical to avoid in ensuring accurate preparation and access to imaging for clients with tattoos.

Choice D reason: Iodine allergy is relevant for CT contrast, not MRI, which uses gadolinium; patches are priority. Assuming iodine allergy contraindicates MRI risks misinformation, potentially delaying imaging, critical to prevent in ensuring proper preparation and safety for clients undergoing MRI scans.

A. Wear gloves to apply the patch to the client’s skin. B. Remove the previous patch and place it in a tissue. C. Apply the patch within 1 hour of removing it from the protective pouch. D. Shave hairy areas of skin prior to application.

Correct Answer is A

Explanation

Choice A reason: Wearing gloves prevents nicotine absorption through the nurse’s skin during patch application, ensuring safety and preventing side effects like dizziness. This adheres to standard precautions, critical for occupational health, maintaining hygiene, and ensuring effective nicotine therapy for clients in smoking cessation programs.

Choice B reason: Removing the previous patch is correct but placing it in tissue is inadequate; it should be folded and disposed in a sharps container. Assuming tissue disposal is sufficient risks improper handling, potentially exposing others to nicotine, critical to avoid in safe patch management.

Choice C reason: Applying the patch within 1 hour of pouch removal is unnecessary; patches remain stable longer. Wearing gloves is priority. Assuming time restriction risks rushed application, potentially compromising technique, critical to prevent in ensuring safe and effective nicotine patch therapy for smoking cessation.

Choice D reason: Shaving hairy areas risks skin irritation; trimming is preferred before patch application. Wearing gloves is essential. Assuming shaving is correct risks skin damage, reducing patch adhesion, critical to avoid in ensuring proper application and effective nicotine delivery in smoking cessation therapy.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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