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 D
Explanation
Choice A rationale
An increase in intraocular pressure is not a cause of diabetic retinopathy. Diabetic retinopathy is caused by damage to the blood vessels in the retina due to high blood sugar levels.
Choice B rationale
While regular eye exams are important for patients with diabetes mellitus, having an eye exam every 2 years may not be sufficient for detecting and managing diabetic retinopathy. More frequent eye exams may be recommended depending on the patient’s condition.
Choice C rationale
Clouding of the lens is not a manifestation of diabetic retinopathy. This is a symptom of cataracts, not diabetic retinopathy. Diabetic retinopathy affects the blood vessels in the retina, not the lens of the eye.
Choice D rationale
Seeing spots, also known as floaters, is a common symptom of diabetic retinopathy. This occurs when blood and other fluids leak into the vitreous, the clear, jelly-like substance that fills the inside of the eye.
Correct Answer is D
Explanation
For a patient with hypoglycemia who has experienced a suspected seizure, the immediate intervention would be to administer IV 0.9% sodium chloride and 5% glucose (dextrose). This helps to quickly raise the patient’s blood glucose levels and manage the seizure.
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