A nurse is caring for a client who is 2 hr postoperative. Which of the following findings should the nurse report to the provider?

The client reports a pain level of 2 on a 0 to 10 scale after administration of pain medication.

The client has a urine output of 50 mL/hr after removal of the indwelling urinary catheter.

The client has a wound dressing saturated with sanguinous drainage after it was reinforced.

The client has an oxygen saturation level of 96% after oxygen 2 L/min via nasal cannula was applied.

Answer and Explanation

The Correct Answer is C

Rationale:
A. The client reports a pain level of 2 on a 0 to 10 scale after administration of pain medication: A pain level of 2 indicates adequate pain control following surgery, showing that the prescribed analgesic regimen is effective. This finding does not require reporting.

B. The client has a urine output of 50 mL/hr after removal of the indwelling urinary catheter: A urine output of 50 mL/hr is within normal limits and indicates adequate renal perfusion. This finding suggests that kidney function and fluid balance are appropriate after surgery.

C. The client has a wound dressing saturated with sanguineous drainage after it was reinforced: Saturation of the surgical dressing with sanguineous drainage can indicate active bleeding or hemorrhage. Because this exceeds normal postoperative drainage and persists after reinforcement, it requires immediate notification of the provider.

D. The client has an oxygen saturation level of 96% after oxygen 2 L/min via nasal cannula was applied: An oxygen saturation of 96% indicates effective oxygenation and a positive response to therapy. This finding is within normal range and does not signal a complication.

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Correct Answer is C

Explanation

Rationale:
A. Hypovolemia: Hypovolemia causes a decrease in PAWP due to reduced circulating blood volume and inadequate venous return to the heart. A low PAWP reflects decreased left ventricular preload, not an elevated value.

B. Hypotension: Hypotension alone does not directly increase PAWP. In fact, low blood pressure often accompanies decreased cardiac filling pressures. Elevated PAWP typically occurs with fluid overload or impaired ventricular function rather than simple hypotension.

C. Left ventricular failure: An elevated PAWP indicates increased left-sided heart pressures due to ineffective left ventricular pumping. Blood backs up into the pulmonary circulation, leading to pulmonary congestion and edema.

D. Cardiogenic shock: In cardiogenic shock, PAWP can be elevated due to impaired contractility, but it is accompanied by low cardiac output and hypotension. While related, the elevated PAWP in cardiogenic shock results from the underlying left ventricular failure, which is the primary cause of the pressure increase.

A. Assess pressure points every 24 hr. B. Turn and reposition the client every 3 hr while in bed. C. Teach the client to shift his weight every 15 min while sitting. D. Place the client upright ona donut-shaped cushion.

Correct Answer is C

Explanation

Rationale:
A. Assess pressure points every 24 hr: Skin assessment should be performed at least every shift or more frequently in high-risk clients. Waiting 24 hours between assessments increases the risk of progression from erythema to ulceration due to unrelieved pressure.

B. Turn and reposition the client every 3 hr while in bed: Clients at risk for pressure injuries should be repositioned at least every 2 hours in bed to promote circulation and reduce tissue ischemia. Extending this interval to 3 hours is inadequate for prevention or healing.

C. Teach the client to shift his weight every 15 min while sitting: Teaching the client to perform weight shifts every 15 minutes reduces pressure on the ischial areas, promoting blood flow and preventing further skin breakdown. This intervention empowers self-care and is a key preventive strategy for wheelchair-bound clients.

D. Place the client upright on a donut-shaped cushion: Donut cushions can impair circulation around the pressure site by concentrating pressure on surrounding tissue, worsening ischemia and tissue damage. Pressure-redistribution cushions or gel pads are safer alternatives.

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A nurse is caring for a client who is 2 hr postoperative. Which of the following findings should the nurse report to the provider?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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