A nurse is caring for a client who is 6 hr postoperative following a bowel resection. Which of the following findings is the priority for the nurse to report?
The client arouses easily but quickly falls back asleep.
There is 20 mL of dark red drainage from the wound drainage device over the past 4 hr.
There is 60 mL of dark yellow urine from the indwelling urinary catheter over the past 4 hr.
The client reports a pain level of 6 on a scale from 0 to 10 at the incision site.
The Correct Answer is A
A. The client arouses easily but quickly falls back asleep. This could indicate a potential complication, such as a postoperative haemorrhage, hypovolemia which can lead to decreased perfusion and oxygenation.
B. 20 mL of dark red drainage over 4 hours: This is expected postoperative output.
C. 60 mL of dark yellow urine over 4 hours: This is a low output but not immediately critical compared to potential hypoxia.
D. Pain level of 6/10 at the incision site: Pain is expected and manageable with interventions, making it less critical.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
A. Findings of right lower extremity assessment: The diminished pulses, cool temperature, and reduced sensation of the right foot suggest impaired circulation and potential compartment syndrome, which is an emergency.
B. Pain level: A pain level of 10/10 that is disproportionate to the injury indicates a need for immediate evaluation, as it may signal compartment syndrome.
C. Level of consciousness: Not concerning as the client is alert and denies loss of consciousness.
D. Oxygen saturation: Normal at 97%.
E. Right pedal pulses: A diminished pedal pulse (1+) on the right is a critical finding that requires urgent intervention to restore circulation.
F. Temperature: A temperature of 36°C is within normal limits and does not require follow-up.
G. X-ray results: Confirms the fracture but is not a finding requiring immediate follow-up compared to circulatory concerns.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
The first action the nurse should take is to assess neurovascular status followed by notify the provider.
- Assess neurovascular status first: The diminished pulses and coolness of the right foot indicate compromised circulation, requiring immediate evaluation to confirm the severity.
- Notify the provider: Once the critical assessment findings are confirmed, notifying the provider for prompt intervention is essential to prevent further complications.
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