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 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 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 Correct Answer is A
Choice A reason: Saturated sanguinous drainage post-reinforcement signals excessive bleeding, potentially indicating hemorrhage or poor wound healing. Two hours postoperative, this suggests vascular injury or coagulopathy, requiring urgent provider notification to prevent hypovolemia, infection, or further complications in the surgical site.
Choice B reason: Oxygen saturation of 96% on 2 L/min nasal cannula is normal (95-100%), indicating stable respiratory status. This does not require reporting, as it reflects effective oxygenation post-surgery, with oxygen therapy appropriately supporting recovery without signs of respiratory distress.
Choice C reason: A pain level of 2/10 post-medication indicates effective pain control, not warranting immediate reporting. Postoperative pain management targets comfort (<4/10), and this level suggests successful analgesia, with no evidence of complications like nerve injury requiring provider intervention.
Choice D reason: Urine output of 50 mL/hr is normal (>30 mL/hr) post-catheter removal, indicating adequate renal perfusion. This does not require reporting, as it reflects normal kidney function and hydration status in the early postoperative period, absent other concerning symptoms.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Removing restraints immediately risks safety, as the client’s calm state may not be sustained. Restraints require gradual removal after ensuring sustained behavioral stability, per facility policy and safety standards. Frequent monitoring is needed to assess ongoing safety, making this action premature and potentially unsafe.
Choice B reason: Encouraging group therapy is inappropriate while the client remains in restraints, as it does not address the immediate need to evaluate their behavior for safe restraint removal. Therapy may be beneficial later, but ongoing monitoring is the priority to ensure safety and compliance with restraint protocols.
Choice C reason: Continuing to monitor the client every 15 minutes ensures safety while assessing sustained calm and cooperative behavior. This adheres to restraint protocols, which require frequent checks to evaluate the need for continued restraint, prevent complications, and plan for safe removal, making it the correct action.
Choice D reason: Administering a sedative to maintain calm behavior is inappropriate without a current medical order or ongoing aggression. Sedatives carry risks like oversedation or respiratory depression. Monitoring the client’s behavior is the priority to determine if restraints can be safely discontinued, making this action unnecessary and potentially harmful.
Correct Answer is C
Explanation
Choice A reason: Reassuring the client about future children minimizes her current grief and loss, which is inappropriate during initial grieving. This dismisses the emotional significance of the stillbirth, potentially causing distress, making it an insensitive and incorrect action.
Choice B reason: Discouraging friends from seeing the newborn restricts the client’s support system and grieving process. Allowing such interactions can provide closure and comfort, so this action is counterproductive and insensitive, making it incorrect for supporting grief.
Choice C reason: Offering to take pictures of the newborn provides a tangible memory, supporting the client’s grieving process. This sensitive intervention validates the loss and aids emotional healing, aligning with best practices for stillbirth care, making it the correct action.
Choice D reason: Advising against discussing the stillbirth isolates the client and hinders grief processing. Open communication with family fosters support and healing, so this action is harmful and contradicts grief support principles, making it incorrect.
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