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
Laying down 30 minutes after eating can actually worsen GERD symptoms. This is because the position can make it easier for stomach acid to back up into the esophagus.
Choice B rationale
Practicing good oral hygiene is important for everyone, but it doesn’t directly prevent GERD. However, it can help prevent complications of GERD such as tooth decay caused by stomach acid.
Choice C rationale
While moderate alcohol consumption may reduce stress, it can actually worsen GERD. Alcohol can relax the lower esophageal sphincter, allowing stomach acid to reflux into the esophagus. It can also increase stomach acid production.
Choice D rationale
Citrus foods are generally not recommended for people with GERD. They are acidic and can trigger GERD symptoms. Instead, non-citrus fruits like bananas, apples, and pears are better choices.
Correct Answer is C
Explanation
Choice A rationale
While having a room within view of the nurses’ station can be beneficial for monitoring the patient, it does not specifically address the needs of a patient with active tuberculosis.
Choice B rationale
Placing a patient with active tuberculosis in a room with another non-surgical patient could potentially expose the other patient to the disease. Tuberculosis is an airborne disease and can easily spread to others in close proximity.
Choice C rationale
A room with air exhaust directly to the outdoor environment is the most appropriate choice for a patient with active tuberculosis. This type of room, known as a negative pressure room, helps prevent the spread of airborne diseases like tuberculosis. The air in the room is vented outside, reducing the risk of the disease spreading to other areas of the hospital.
Choice D rationale
While the ICU is equipped to handle severe and critical cases, a patient with active tuberculosis does not necessarily need to be in the ICU unless they are critically ill. Moreover, placing them in the ICU could potentially expose other critically ill patients to tuberculosis.
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