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 B
Explanation
Choice A reason: Clients with borderline personality disorder (BPD) typically exhibit an unstable sense of self and tumultuous relationships, not stability. Their identity disturbances and fear of abandonment lead to chaotic interpersonal dynamics, making this statement incorrect as it misrepresents core BPD characteristics.
Choice B reason: Self-harming behaviors, such as cutting or suicidal gestures, are common in BPD due to emotional dysregulation and impulsivity. These actions serve as maladaptive coping mechanisms for intense emotions, aligning with DSM-5 criteria for BPD, making this the correct information to include.
Choice C reason: While group therapy can be beneficial, dialectical behavior therapy (DBT), an individual and skills-based approach, is the primary evidence-based treatment for BPD. Group therapy alone is not the standard, as it may not address individual emotional regulation needs, making this statement inaccurate.
Choice D reason: Clients with BPD frequently experience mood swings and emotional instability, a hallmark of the disorder due to affective dysregulation. This contradicts the statement, as BPD involves rapid mood shifts, not stability, making this information incorrect for describing BPD characteristics.
Correct Answer is B
Explanation
Choice A reason: Assigning all staff to the emergency department disrupts care for existing inpatients and may overwhelm ED operations. Staff allocation should follow a triage plan, balancing hospital-wide needs. This action is impractical and risks neglecting other patients, making it less effective than preparing resources.
Choice B reason: Preparing to discharge stable clients frees up beds for incoming casualties, optimizing hospital capacity during a mass casualty event. This aligns with disaster protocols, ensuring resources are available for critical patients. It supports efficient triage and care delivery, making it the correct action.
Choice C reason: Canceling all elective surgeries immediately is premature without assessing the event’s scope. Some surgeries may continue if resources allow, per disaster protocols. This action disrupts hospital operations unnecessarily and is less urgent than preparing beds for casualties, making it inappropriate.
Choice D reason: Requesting ventilators assumes specific needs without assessing the casualty event’s nature. Ventilators may not be immediately required, and resource allocation should follow triage protocols. Preparing beds is a more immediate and versatile action, making this choice less prioritized in the initial response.
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