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
Increasing calorie intake by 200 cal per day may not be beneficial for this client. The client has a BMI of 26, which is considered overweight. Therefore, a goal to increase calorie intake may contribute to further weight gain.
Choice B rationale
Listing foods that are high in calcium which should be avoided is not a relevant goal for this client. Calcium is an essential nutrient and there is no indication that the client needs to avoid it.
Choice C rationale
Replacing cigarettes with smokeless tobacco products is not a healthy goal. Smokeless tobacco products also contain harmful chemicals and can lead to health problems.
Choice D rationale
Walking for 30 min 5 days a week is a beneficial goal for this client. Regular physical activity can help manage weight, lower blood pressure, and reduce the risk of heart disease. It can also help the client quit smoking by reducing cravings and withdrawal symptoms.
Correct Answer is D
Explanation
Choice A rationale
This statement is not entirely accurate. Crohn’s disease does not resemble a second-degree burn. It is an inflammatory bowel disease that can affect any part of the gastrointestinal tract.
Choice B rationale
While this statement is technically correct, it uses medical jargon that may be difficult for a patient to understand. Crohn’s disease is indeed characterized by transmural granulomatous inflammation, meaning it affects the entire wall of the gastrointestinal tract. However, this description may not be easily understood by a patient without a medical background.
Choice C rationale
This statement is partially correct but not entirely accurate. Crohn’s disease can cause inflammation in the mucosa and sub-mucosa of the colon and rectal linings, but it is not limited to these areas. It can affect any part of the gastrointestinal tract from the mouth to the anus.
Choice D rationale
This is the most simplistic and non-medical description of the disorder. Crohn’s disease can indeed give the appearance of a “patchwork quilt” in the gastrointestinal tract, with some areas
clear and others inflamed or ulcerated. This description provides a visual analogy that may be easier for a patient to understand.
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