A nurse is assisting with the care of client who is 6 hr postoperative. Which of the following findings should the nurse report to the provider?
Serosanguinous drainage on dressing
Hypoactive bowel sounds
Urinary output of 25 mL/hr
Pain level of 2 on 0 to 10 scale
The Correct Answer is C
A. Serosanguinous drainage on dressing: Serosanguinous drainage, which is a mixture of clear and blood-tinged fluid, is a common and expected finding in the early postoperative period. It typically indicates normal healing unless the amount becomes excessive or the drainage changes character.
B. Hypoactive bowel sounds: Hypoactive bowel sounds are common within the first 24 to 48 hours following surgery, especially after general anesthesia or abdominal procedures. This finding is expected and does not immediately require provider notification unless accompanied by other concerning signs like severe abdominal distention.
C. Urinary output of 25 mL/hr: Urinary output should be at least 30 mL/hr to indicate adequate kidney perfusion and hydration. An output of 25 mL/hr suggests possible hypovolemia, renal impairment, or urinary retention, and it should be promptly reported to the provider for further evaluation.
D. Pain level of 2 on 0 to 10 scale: A pain score of 2 indicates mild pain, which is manageable and expected after surgery. This level of discomfort does not require urgent reporting to the provider as long as it remains controlled and does not interfere with recovery activities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A client who has a urinary tract infection: A urinary tract infection is generally straightforward to manage with antibiotics and does not usually require input from multiple disciplines unless complications arise.
B. A client who has a spinal cord injury: A spinal cord injury often involves complex care needs requiring input from several disciplines, including physical therapy, occupational therapy, nursing, social work, and nutrition services. Coordinated planning is essential to optimize recovery and long-term management.
C. A client who has acute appendicitis: Acute appendicitis typically requires prompt surgical intervention but does not usually require an interprofessional conference unless there are unusual complications or comorbidities.
D. A client who has a torn rotator cuff: A torn rotator cuff is typically managed with surgical repair or physical therapy. While it may involve multiple providers, it generally does not require a full interprofessional conference unless extensive rehabilitation needs are anticipated.
Correct Answer is B
Explanation
A: Image A shows the ankle area, which is an example of a hinge joint, not a ball and socket joint. Hinge joints allow movement in one plane, such as flexion and extension, similar to the motion of a door hinge. The ankle allows primarily up-and-down movement but does not rotate in multiple directions like a ball and socket joint would.
B: Image B shows the hip area, which represents a ball and socket joint. In a ball and socket joint, the round head of one bone fits into the cup-like socket of another bone, allowing movement in multiple directions. The hip and the shoulder are classic examples of ball and socket joints, permitting rotation, flexion, extension, abduction, and adduction.
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