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 B
Explanation
Choice A rationale
Maintaining systolic BP between 136 and 140 mm Hg is not recommended for clients who have hypertension and have experienced a TIA789. Studies have shown that maintaining a lower systolic BP can help reduce the risk of recurrent stroke.
Choice B rationale
The client should aim to maintain systolic BP between 120 and 129 mm Hg. This range is associated with a reduced risk of recurrent stroke. Lifestyle modifications and antihypertensive therapy can help achieve this target.
Choice C rationale
Maintaining systolic BP between 141 and 145 mm Hg is not recommended for clients who have hypertension and have experienced a TIA789. This range is higher than the recommended target and may increase the risk of recurrent stroke.
Choice D rationale
Maintaining systolic BP between 130 and 135 mm Hg is not the recommended target for clients who have hypertension and have experienced a TIA789. The recommended target is lower to help reduce the risk of recurrent stroke.
Correct Answer is B
Explanation
Choice A rationale
Asking why the patient thinks the copper helps with their arthritis might seem like a good way to understand their beliefs, but it could come off as challenging or dismissive.
Choice B rationale
Acknowledging that the patient feels better wearing the bracelet is a respectful response. It validates the patient’s experience without endorsing the effectiveness of copper bracelets, which lack scientific evidence for treating arthritis.
Choice C rationale
This response could be seen as dismissive of the patient’s beliefs and experiences. It’s important to respect patients’ choices in managing their symptoms, as long as those choices aren’t harmful.
Choice D rationale
While it’s true that there’s no scientific basis for believing objects have powers to make you feel better, saying this could come off as dismissive or disrespectful.
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