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 C
Explanation
A. "How often do you have trouble sleeping?": While this question might help assess general sleep issues, it doesn’t specifically address narcolepsy symptoms. Narcolepsy is characterized by excessive daytime sleepiness and episodes of sudden muscle weakness.
B. "Do you snore loudly?": Loud snoring is more commonly associated with sleep apnea rather than narcolepsy. Although both conditions can affect sleep quality, this question doesn’t directly relate to the hallmark symptoms of narcolepsy.
C. "Do you ever suddenly lose muscle control?": Sudden loss of muscle control, or cataplexy, is a key symptom of narcolepsy. Cataplexy occurs when a person experiences sudden muscle weakness or paralysis in response to strong emotions, such as laughter or surprise.
D. "Do you wake up with headaches?": Waking up with headaches could be related to sleep disorders such as sleep apnea or tension headaches, but it is not a defining feature of narcolepsy. The nurse should focus on symptoms directly related to narcolepsy.
Correct Answer is A
Explanation
A. Holds linens close to the body: Holding linens close to the body reduces the risk of contamination and ensures that the linens do not touch potentially unclean surfaces. This practice helps maintain medical asepsis by preventing the spread of microorganisms.
B. Shakes soiled linens before placing them in the hamper: Shaking soiled linens can cause microorganisms to become airborne and spread. To maintain asepsis, linens should be handled gently and placed directly into the hamper without shaking.
C. Puts unneeded clean linens in the hamper: Clean linens should not be placed in the hamper as they could become contaminated. Clean linens should be stored in a clean area to maintain their aseptic state until needed.
D. Places soiled linens on the floor: Placing soiled linens on the floor introduces the risk of contamination, as the floor is not considered a clean surface. Soiled linens should be placed directly into a designated container to maintain medical asepsis.
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