A nurse is assessing a client who is 8 hr postoperative following a right-modified radical mastectomy. Which of the following should the nurse recognize as the priority finding?
Urinary output of 100 mL in 4 hr
Coughing frothy, pink secretions
Emesis of 110 mL of thick, yellow fluid
Red drainage on the dressing
The Correct Answer is B
A. Urinary output of 100 mL in 4 hr: This indicates a urine output of 25 mL/hr, which is slightly below the expected minimum of 30 mL/hr for adequate renal perfusion. While important to monitor, it is not immediately life-threatening compared to respiratory compromise.
B. Coughing frothy, pink secretions: Frothy, pink sputum can indicate pulmonary edema, a potentially life-threatening condition that requires immediate assessment and intervention to prevent respiratory failure. Airway and oxygenation take priority in the postoperative client.
C. Emesis of 110 mL of thick, yellow fluid: Postoperative vomiting is concerning for nausea or potential infection, but it is not immediately life-threatening. Management includes antiemetics and monitoring for dehydration.
D. Red drainage on the dressing: Some postoperative bleeding is expected, especially in the first few hours after surgery. While the nurse should monitor for excessive hemorrhage, small amounts of red drainage are less urgent than signs of pulmonary compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Candidiasis: Candidiasis is a common fungal infection and is not a nationally notifiable disease. Reporting to the CDC is not required for routine cases.
B. Pelvic inflammatory disease: PID is a complication of sexually transmitted infections, but it itself is not a reportable condition. The underlying infection, if it is a notifiable STI, may need to be reported instead.
C. Methicillin-resistant Staphylococcus aureus: MRSA infections acquired in the community or healthcare settings are not universally reportable to the CDC. Reporting requirements vary by state, but MRSA is generally monitored rather than mandatorily reported nationally.
D. Syphilis: Syphilis is a nationally notifiable sexually transmitted infection. Cases must be reported to local and state health departments, which then notify the CDC. This allows for public health tracking, contact tracing, and prevention of further transmission.
Correct Answer is B
Explanation
A. Extend the client's legs above heart level: Elevating the legs may improve venous return but does not reduce tension on the abdominal incision or help prevent further dehiscence. It does not address the immediate concern of protecting the surgical site.
B. Place the client in a low-fowler's position: Positioning the client in a low-Fowler’s position (head of bed at 15–30 degrees) helps reduce intra-abdominal pressure on the incision and prevents further separation of the wound edges. This positioning supports comfort and minimizes strain while preparing for dressing application or further intervention.
C. Instruct the client to perform the Valsalva maneuver: Asking the client to strain or hold their breath increases intra-abdominal pressure, which can worsen dehiscence and increase the risk of evisceration. This action is unsafe and should be avoided.
D. Apply a dry gauze dressing to the incision: Applying a dry dressing alone does not protect the exposed tissue and may increase the risk of infection if evisceration occurs. The initial priority is to reduce tension on the wound by positioning before implementing sterile protective measures, such as a saline-moistened sterile dressing if necessary.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.