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 D
Explanation
A. Promote bonding by encouraging the guardians to formula feed their newborn: Bonding occurs through close physical contact, responsiveness, and nurturing care, regardless of the feeding method. Bonding is important regardless of feeding method, but feeding choice should be based on the guardians’ preference, not directed solely by the nurse. Formula feeding is not necessary for promoting bonding.
B. Encourage guardians to allow relatives to provide the majority of the care for their newborn: Guardians should be encouraged to provide the majority of the newborn's care themselves to strengthen attachment and build confidence in their parenting abilities.
C. Ensure guardians know that criticism of newborn care is acceptable: Criticism can undermine the guardians' confidence and create stress. Support and positive reinforcement are important for helping new parents feel secure in their roles.
D. Inform guardians how to respond to their newborn's cues: Teaching guardians how to recognize and respond to their newborn's cues, such as hunger, discomfort, or need for interaction, promotes bonding, supports emotional development, and strengthens the parent-newborn relationship.
Correct Answer is D
Explanation
A. The client recently received a pay raise at work: Receiving a pay raise is generally considered a positive life event that can improve self-esteem and financial security. Positive achievements like this are not associated with increased suicide risk and may actually serve as protective factors against depressive symptoms.
B. The client is married and has children: Being married and having children are typically viewed as protective factors against suicide. Strong familial bonds and social connections provide emotional support, a sense of responsibility, and a buffer against feelings of isolation or hopelessness that often contribute to suicidal ideation.
C. The client has a strong religious affiliation: Strong religious beliefs can serve as a significant protective factor against suicide by providing hope, purpose, community support, and moral objections to self-harm. Clients with strong spiritual ties often demonstrate greater resilience during periods of emotional distress.
D. The client has a history of chronic back pain: Chronic pain is a known risk factor for suicide because it can lead to feelings of hopelessness, helplessness, and a diminished quality of life. Clients with long-term physical pain often experience comorbid depression and are at higher risk for suicidal thoughts and behaviors.
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