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
Answer and explanation
The correct answer is choice B.
Choice A rationale:
Yoga involves gentle stretching and may not directly impact the phlebitis.
Choice B rationale:
Therapeutic massage could potentially dislodge a clot in the leg, leading to a dangerous condition called a pulmonary embolism.
Choice C rationale:
Acupressure, like yoga, involves gentle pressure and may not directly impact the phlebitis.
Choice D rationale:
Acupuncture involves the insertion of needles and could potentially cause harm, but it is less likely to dislodge a clot than massage.
Correct Answer is B
Explanation
Choice A rationale:
"The use of social media is not included in the COE.”. This statement is not accurate. The use of social media is addressed in the Code of Ethics (COE) for nurses. The COE provides guidance on how nurses should maintain professional boundaries and ethical behavior in the digital age, which includes considerations for social media use.
Choice B rationale:
"Professional expectations are included in the COE.”. This statement is correct. The Code of Ethics (COE) for nurses outlines the professional expectations and standards that nurses are expected to adhere to. It provides guidance on ethical conduct, accountability, and the responsibilities of nurses in their practice.
Choice C rationale:
"Student nurses are not held accountable to COE.”. This statement is not accurate. Student nurses are expected to adhere to the same ethical standards outlined in the Code of Ethics (COE) as registered nurses. While there may be some variations in practice expectations based on the level of training, ethical principles apply to all nurses, including student nurses.
Choice D rationale:
"Criteria for obtaining licensure is included in the COE.”. This statement is not accurate. The Code of Ethics (COE) primarily focuses on ethical principles, professional behavior, and the responsibilities of nurses in their practice. It does not typically include criteria for obtaining licensure, as licensure requirements are determined by licensing boards and regulatory bodies.
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