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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Routine health screenings are part of secondary prevention, focusing on early detection of diseases before symptoms appear. Tertiary prevention addresses management after diagnosis, so this action is misaligned with the phase, making it incorrect for the workshop content.
Choice B reason: Administering vaccinations is primary prevention, aimed at preventing diseases before they occur. Tertiary prevention involves managing existing conditions, so vaccinations do not fit this phase, making this an incorrect choice for interprofessional care focus.
Choice C reason: Developing a rehabilitation plan post-stroke is tertiary prevention, as it minimizes disability and improves function after a disease event. This collaborative effort involves multiple disciplines (e.g., PT, OT), aligning with interprofessional care goals, making it the correct choice.
Choice D reason: Educating about healthy lifestyles is primary prevention, promoting health to prevent disease onset. Tertiary prevention focuses on managing established conditions, so this action is incorrect for the tertiary phase in interprofessional collaboration.
Correct Answer is A
Explanation
Choice A reason: Using two identifiers (e.g., name and medical record number) ensures the correct client receives the medication, preventing errors. This aligns with safety protocols, reducing risks of administering drugs to the wrong person. Verification confirms identity before administration, safeguarding against adverse events and ensuring compliance with standards like The Joint Commission.
Choice B reason: Checking the medication label twice is part of the “rights” of administration but is less specific than using two identifiers for client verification. While important, it addresses medication accuracy, not client identity, which is the primary safety concern to prevent errors, making it less critical in this context.
Choice C reason: Administering medication within 3 hours of the scheduled time relates to timing protocols, not the core action of ensuring safe administration. While timely administration is important, verifying client identity is the priority to prevent errors, as incorrect patient identification can lead to severe adverse events, making this less relevant.
Choice D reason: Administering medications to treat a condition to the actual prescriptions is vague and not a standard safety action. The focus is on verifying client identity and medication accuracy, not a general treatment alignment. This statement does not address a specific, actionable step in safe medication administration, making it incorrect.
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