A nurse is caring for a client who is 4 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
Urine output 25 mL/hr
Heart rate 68/min
Hypoactive bowel sounds
Serosanguineous drainage on surgical dressing
The Correct Answer is A
A. Urine output 25 mL/hr: Urine output less than 30 mL/hr is considered inadequate, especially after surgery. This could indicate possible renal insufficiency or hypovolemia, requiring immediate attention.
B. Heart rate 68/min: A heart rate of 68/min falls within the normal adult range (60-100 beats per minute). This finding is generally considered stable and does not typically indicate an immediate complication requiring urgent reporting to the provider in a postoperative client.
C. Hypoactive bowel sounds: Hypoactive bowel sounds are common in the immediate postoperative period, especially after abdominal surgery. This occurs due to the effects of anesthesia and bowel manipulation.
D. Serosanguineous drainage on surgical dressing: Serosanguineous drainage is typical in the early postoperative period and usually decreases over time. It’s not abnormal unless the amount increases significantly or the drainage becomes purulent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Assess the client every hr for circulation, possible injury, and readiness for discontinuation: While regular assessment is necessary, it should be done more frequently than every hour. A check every 15-30 minutes is recommended for safety.
B. Check the client's peripheral pulses and skin integrity every 15 min: Frequent assessments of circulation, skin integrity, and injury help prevent complications like tissue damage or nerve impairment.
C. Assist the client with passive range of motion exercises every 3 hr: Passive range of motion exercises should be done more frequently than every 3 hours to prevent stiffness and joint contractures.
D. Attach the extremity restraint straps to the bed rails using a quick-release buckle: Restraints should never be attached to bed rails, as this increases injury risk. Straps should be secured to a stationary part of the bed frame.
Correct Answer is B
Explanation
A. Discuss the client's condition with a nurse on another unit: Sharing a client’s condition with a nurse on another unit without a need-to-know basis violates confidentiality rules. Discussions about client conditions should be limited to personnel involved in care.
B. Fax client information with a cover sheet: A fax cover sheet protects the confidentiality of client information by identifying the contents and indicating that it is confidential. This ensures that the information is not exposed to unauthorized individuals during transmission.
C. List the client's name and condition on board at the nurses station: Displaying client information in public or semi-public areas, violates confidentiality. Client information should be kept private and only accessed by those who are involved in the client’s care.
D. Post client diagnosis on message board in their room: Posting the client’s diagnosis in their room is a violation of confidentiality, as other individuals (like visitors or hospital staff) may have access to that information without a need to know.
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