A nurse is caring for a client who is 3 hr postoperative following abdominal surgery.
Which of the following assessment data should the nurse report to the provider?
Serosanguineous drainage noted on the abdominal dressing.
Postoperative laboratory results are Hgb 15% and Hct 40%.
The client's urine output has been 50 mL since surgery.
The client's pain level has decreased since the administration of morphine.
The Correct Answer is C
Choice A rationale:
Serosanguineous drainage noted on the abdominal dressing is a common finding in the early postoperative period. It is a mixture of clear and bloody drainage and is often seen after surgery. This does not typically require immediate reporting unless it becomes excessive or changes significantly. The nurse can continue to monitor and assess the situation.
Choice B rationale:
Postoperative laboratory results of Hgb 15% and Hct 40% are within the normal range for most adults, and there is no immediate need to report these results to the provider. These values suggest that the client's hemoglobin and hematocrit levels are within an acceptable range, indicating adequate oxygen-carrying capacity.
Choice C rationale:
The client's urine output has been 50 mL since surgery, which is significantly decreased and could indicate a potential issue with renal function or fluid balance. This should be reported to the provider, as it may be indicative of kidney impairment, dehydration, or other postoperative complications.
Choice D rationale:
The client's pain level decreasing after the administration of morphine is an expected response to pain management interventions. There is no need to report this information to the provider unless the pain relief is inadequate or the client experiences adverse effects. Pain management is an essential part of postoperative care, and successful pain reduction is a positive outcome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Including a note in the medical record that an incident report was completed is a crucial step in documenting the event. It serves as a legal and organizational record of the incident, providing transparency and accountability. This information can be essential for tracking trends, identifying areas for improvement, and ensuring patient safety.
Choice B rationale:
Identifying other people involved with the event in the incident report is also an important step. It helps in determining who was present or responsible during the incident, which can be crucial in investigating the event and identifying potential areas for process improvement.
Choice C rationale:
Including personal opinions regarding an event in an incident report is not advisable. Incident reports should focus on factual, objective information. Personal opinions can introduce bias and subjectivity, which may not be helpful in addressing the root causes of the incident or improving the quality of care.
Choice D rationale:
Identifying the person responsible for the error in the incident report is a valid step, as it helps in assigning accountability and addressing any systemic issues that may have contributed to the error. However, it's essential to do so without assigning blame or making judgments. The emphasis should be on improving processes and preventing similar incidents in the future.
Correct Answer is B
Explanation
The correct answer is Choice B: Nursing Scope and Standards of Practice.
Choice A rationale:
The Code of Ethics for Nurses provides guidelines on ethical practice but does not specifically address pay.
Choice B rationale:
The Nursing Scope and Standards of Practice outlines the professional standards, including aspects related to compensation and benefits, which can help guide a nurse in understanding pay scales and expectations.
Choice C rationale:
American Nurses Association Position Statements provide guidance on various issues but are not focused on pay.
Choice D rationale:
Principles of Nursing Practice offer a framework for nursing care but do not specifically address salary or compensation.
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