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
Ceasing from smoking and consuming alcohol is crucial for patients who have been treated for acute pancreatitis. Both smoking and alcohol consumption can cause further damage to the pancreas and lead to recurrent episodes of pancreatitis.
Choice B rationale
While wearing tight-fitting clothing can be uncomfortable for some individuals, it does not have a direct impact on the recovery from acute pancreatitis.
Choice C rationale
Stopping exercise is not typically recommended for patients recovering from acute pancreatitis. Regular physical activity is generally beneficial for overall health, although a healthcare provider may recommend specific types or amounts of exercise based on the individual’s condition.
Choice D rationale
While practicing good dental hygiene is important for overall health, it does not specifically relate to the treatment or prevention of acute pancreatitis.
Correct Answer is D
Explanation
Choice A rationale
Documenting the bowel sounds as hypoactive is not the most appropriate action. Hypoactive bowel sounds are fewer than three bowel sound events in a minute or none at all. However, the absence of bowel sounds does not necessarily mean they are hypoactive. It could be due to other reasons such as ileus.
Choice B rationale
Administering prescribed drugs for constipation is not the immediate course of action when the nurse doesn’t hear any gurgling while listening to bowel sounds. Constipation is a condition that can cause hypoactive bowel sounds, but it’s not the only reason for the absence of bowel sounds. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice C rationale
Reviewing dietary intake for the past 24 hours is not the immediate course of action. While diet can affect bowel sounds, it’s not the first step when bowel sounds are not heard. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice D rationale
The correct action when the nurse doesn’t hear any gurgling while listening to bowel sounds is to continue to listen for at least another 60 seconds. Bowel sounds are produced by the movement of fluid, gas, and contents through the intestines. An absence of bowel sounds for greater than two minutes may indicate that there is no peristalsis—which implies an ileus.
Therefore, the nurse should continue to listen for at least another 60 seconds to confirm the absence of bowel sounds.
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.
