A nurse is assessing a patient who is 48 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
Blood pressure 102/66 mm Hg
Yellow-green drainage on the surgical incision
Respiratory rate 18/min
Straw-colored urine from an indwelling urinary catheter
The Correct Answer is B
Choice A rationale
A blood pressure of 102/66 mm Hg is within the normal range and would not typically need to be reported to the provider.
Choice B rationale
Yellow-green drainage on the surgical incision could be a sign of a wound infection. Infections after surgery can lead to serious complications and should be reported to the provider immediately.
Choice C rationale
A respiratory rate of 18/min is within the normal range and would not typically need to be reported to the provider.
Choice D rationale
Straw-colored urine from an indwelling urinary catheter is normal and would not typically need to be reported to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The effectiveness of pancreatic enzyme replacement therapy in patients with chronic pancreatitis can be evaluated by observing the patient’s stool. Pancreatic enzyme replacement therapy (PERT) is used to improve digestion and absorption of nutrients in patients with pancreatic insufficiency, a common complication of chronic pancreatitis. One of the primary goals of PERT is to reduce steatorrhea, or fatty stools, which is a common symptom of pancreatic insufficiency. Therefore, observing changes in the patient’s stool, such as a reduction in fat content, can help evaluate the effectiveness of PERT567.
Choice B rationale
While saliva plays a role in the initial stages of digestion, it is not typically used to evaluate the effectiveness of pancreatic enzyme replacement therapy in patients with chronic pancreatitis. PERT is primarily aimed at improving the digestion and absorption of nutrients in the intestines, and changes in saliva are not indicative of the effectiveness of this therapy.
Choice C rationale
Nasal mucus is not typically used to evaluate the effectiveness of pancreatic enzyme replacement therapy in patients with chronic pancreatitis. PERT is primarily aimed at improving the digestion and absorption of nutrients in the intestines, and changes in nasal mucus are not indicative of the effectiveness of this therapy.
Choice D rationale
Urine is not typically used to evaluate the effectiveness of pancreatic enzyme replacement therapy in patients with chronic pancreatitis. PERT is primarily aimed at improving the digestion and absorption of nutrients in the intestines, and changes in urine are not indicative of the effectiveness of this therapy.
Correct Answer is A
Explanation
Choice A rationale
Providing a quiet, low-stimulus environment is one of the key interventions for a patient with hyperthyroidism who is at risk of a thyroid crisis. Hyperthyroidism is characterized by an overproduction of thyroid hormones, which can accelerate the body’s metabolism causing symptoms such as rapid heart rate, increased appetite, increased perspiration, fatigue, menstrual irregularity, and restlessness. A thyroid crisis, also known as a thyroid storm, is a severe, life-threatening condition characterized by extreme symptoms of hyperthyroidism. A quiet, low-stimulus environment can help reduce anxiety and agitation, which can exacerbate symptoms and potentially trigger a thyroid crisis.
Choice B rationale
Keeping the patient NPO (nothing by mouth) is not typically necessary in the management of hyperthyroidism unless the patient is preparing for a procedure such as thyroid surgery. In
fact, because of the increased metabolic rate in hyperthyroidism, patients often have an increased appetite and may require additional caloric intake.
Choice C rationale
Administering aspirin for any sign of hyperthermia is not recommended in hyperthyroidism. Aspirin can actually increase the level of free thyroid hormones in the blood by displacing them from their binding proteins, potentially worsening the hyperthyroid state.
Choice D rationale
While it is important to observe patients with hyperthyroidism for signs of various complications, hypocalcemia is not typically associated with hyperthyroidism. Hypocalcemia, or low calcium levels in the blood, is more commonly associated with hypoparathyroidism or vitamin D deficiency.
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