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 D
Explanation
Choice A reason: Urine output of 20 mL/hr is below the desired 30 mL/hr during magnesium sulfate therapy, indicating potential toxicity or renal issues, not a therapeutic effect. Absence of eclampsia is the goal. Monitoring for low output risks missing seizure prevention, critical for maternal safety in preeclampsia management.
Choice B reason: Fetal heart rate of 116/min is within normal (110-160/min) but not a direct therapeutic effect of magnesium sulfate, which prevents seizures. Absence of eclampsia is key. Assuming heart rate is the focus risks overlooking maternal neurological status, critical for ensuring seizure prevention in preeclampsia treatment.
Choice C reason: Blood pressure of 150/92 mm Hg, while elevated, is not the primary therapeutic effect of magnesium sulfate, which targets seizure prevention, not hypertension. Absence of eclampsia is priority. Focusing on blood pressure risks neglecting seizure monitoring, critical for maternal safety in preeclampsia management with magnesium.
Choice D reason: Absence of eclampsia (seizures) is the primary therapeutic effect of magnesium sulfate in preeclampsia, stabilizing neuronal excitability, preventing life-threatening convulsions. Monitoring this ensures maternal safety, critical for preventing neurological damage, supporting fetal well-being, and guiding therapy adjustments in high-risk obstetric care.
Correct Answer is C
Explanation
Choice A reason: A communication board is for speech or cognitive issues, not visual impairment, where indirect lighting aids vision. Assuming a board is appropriate risks ineffective communication, potentially frustrating the client, critical to avoid in ensuring clear interaction for visually impaired clients in care settings.
Choice B reason: An interpreter is for language barriers, not visual impairment, where indirect lighting enhances visibility. Assuming an interpreter is needed risks misaligned communication strategies, potentially reducing clarity, critical to prevent in ensuring effective teaching and interaction for clients with visual impairments.
Choice C reason: Indirect lighting reduces glare, improving visibility for visually impaired clients, enhancing communication and safety. This understanding is critical for effective interaction, ensuring client comfort, promoting independence, and supporting accurate information exchange, essential for care delivery in clients with visual impairments.
Choice D reason: Collaborating with a speech therapist addresses speech issues, not visual impairment, where indirect lighting is key. Assuming therapist involvement is relevant risks overlooking visual needs, potentially reducing communication efficacy, critical to avoid in supporting visually impaired clients in healthcare settings.
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