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 C
Explanation
Correct Answer is B
Explanation
Choice A rationale:
Ensuring that the television is on is not a recommended action when providing discharge teaching for an adolescent with a cognitive disorder and their parents. Television noise can be distracting and may hinder effective communication. The focus should be on clear, concise, and tailored communication to address the patient's and family's needs.
Choice B rationale:
Using short directive statements is a suitable approach when teaching a patient with a cognitive disorder and their parents. Patients with cognitive disorders may have difficulty processing complex information, so using concise and straightforward language can enhance understanding. It is essential to adapt teaching strategies to the individual's needs and abilities.
Choice C rationale:
Including medical slang in the teaching is not appropriate, as it can confuse and alienate patients and their families. The goal of discharge teaching is to ensure that the information provided is clear, easily understood, and accessible to the patient and their family. Using medical jargon or slang may hinder this objective.
Choice D rationale:
Including abstract imagery is not recommended when teaching a patient with a cognitive disorder. Abstract imagery can be challenging to understand, especially for individuals with cognitive impairments. Teaching materials should be concrete, straightforward, and tailored to the patient's cognitive abilities and comprehension levels.
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