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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. "Avoid exercising in warm places.": Heat can temporarily worsen symptoms of multiple sclerosis, such as fatigue, weakness, and spasticity, due to slowed nerve conduction. Clients should exercise in cool environments or use cooling techniques to prevent symptom exacerbation.
B. "Walk with your feet close together.": Walking with feet close together can increase the risk of imbalance and falls in clients with MS, who often have gait disturbances. Maintaining a wider stance or using assistive devices improves stability and safety during ambulation.
C. "Decrease your daily fluid intake.": Fluid restriction is not recommended for MS and can lead to dehydration and urinary tract complications. Adequate hydration helps maintain bladder function and overall health.
D. "Apply an ice pack to spastic muscles.": Cold therapy does not effectively relieve muscle spasticity in MS; instead, heat may temporarily reduce muscle stiffness. Ice packs are more appropriate for acute inflammation or injury rather than chronic spasticity.
Correct Answer is D
Explanation
Rationale:
A. Prolonged QT interval: Morphine does not typically cause a prolonged QT interval. QT prolongation is more commonly associated with certain antiarrhythmic or psychotropic medications, not opioid toxicity.
B. Fluid retention: Morphine is not known to cause fluid retention. Signs of toxicity are primarily related to central nervous system and respiratory depression rather than cardiovascular fluid balance.
C. Hyperactive deep tendon reflexes: Morphine toxicity usually depresses neurological function, leading to decreased reflexes rather than hyperactivity. Hyperactive reflexes are not characteristic of opioid overdose.
D. Bradypnea: Respiratory depression, manifested as bradypnea, is a hallmark sign of morphine toxicity. Excessive morphine depresses the brainstem respiratory centers, reducing the rate and depth of respirations, which can be life-threatening if not addressed promptly.
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