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 C
Explanation
Rationale:
A. Oxygen saturation 97% on room air: Adequate oxygenation is essential for wound healing because oxygen supports collagen synthesis and tissue repair. An oxygen saturation of 97% indicates sufficient oxygen delivery to tissues and does not place the client at risk for delayed healing.
B. Pain level of 1 on a scale of 0 to 10: Minimal pain suggests effective postoperative pain management and allows the client to move, breathe deeply, and participate in recovery activities. Pain at this level does not negatively impact the wound-healing process.
C. BMI 35: Obesity is associated with delayed wound healing due to poor vascularity in adipose tissue, which reduces oxygen and nutrient delivery to the wound. Increased tension on wound edges and a higher risk of infection also contribute to impaired healing in obese clients.
D. Capillary refill time 1 second: A capillary refill of 1 second reflects adequate peripheral perfusion, which supports effective oxygen and nutrient delivery to tissues. Normal circulation facilitates the healing process rather than delaying it.
Correct Answer is A
Explanation
Rationale:
A. "I will ask your provider to discuss options for discontinuing treatment with you.": This response supports the client’s autonomy and right to refuse treatment while ensuring that the provider is informed to discuss the medical and ethical aspects of stopping therapy. It reflects respect for the client’s wishes and promotes shared decision-making.
B. "You cannot legally discontinue treatment unless you have a living will.": A living will is not required for a client to refuse or discontinue treatment. Competent clients have the legal and ethical right to make decisions about their own care, including the choice to stop therapy, regardless of advance directives.
C. "You must continue with these treatments because they are lifesaving.": This statement disregards the client’s autonomy and imposes the nurse’s opinion on the client’s decision. Even if the treatment is potentially lifesaving, the client has the right to decline it based on their personal values and quality-of-life considerations.
D. "I know your provider thinks these treatments are necessary for you.": This response shifts focus away from the client’s preferences and reinforces the provider’s opinion instead. It fails to acknowledge the client’s emotional and ethical right to choose.
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