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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
Choice A reason: A mobile 24 inches above the crib is too high for a 1-week-old’s vision (8-12 inches is ideal), indicating misunderstanding. A ticking clock is soothing. Assuming mobile placement is correct risks reduced stimulation, critical to avoid in supporting infant development and parental education.
Choice B reason: Propping a bottle with a pillow risks choking or aspiration in a 1-week-old; holding is required. A ticking clock is correct. Assuming propping is safe risks infant safety, critical to prevent in ensuring proper feeding practices and parental education for newborns.
Choice C reason: Avoiding frequent holding risks neglecting bonding and comfort needs in a 1-week-old; responsive care is essential. A ticking clock is soothing. Assuming avoidance is correct risks developmental issues, critical to avoid in supporting infant emotional health and parental caregiving education.
Choice D reason: Placing a ticking clock nearby mimics womb sounds, soothing a 1-week-old, promoting sleep and comfort. This understanding is critical for infant well-being, supporting parental caregiving, ensuring a calming environment, and fostering healthy development in the early newborn period at home.
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