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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. "Replace wet clothing with warmed blankets.": Hypothermia is a significant concern after near-drowning in cold conditions. Replacing wet clothing with warmed blankets helps stabilize body temperature.
B. "Use an axillary thermometer to monitor the client's temperature.": Axillary thermometers are not accurate for hypothermic clients. Core temperature monitoring is more reliable.
C. "Assist the client to perform range-of-motion exercises.": This is not a priority in acute care following hypothermia or near-drowning.
D. "Administer an antihypertensive medication.": Hypertension is not the focus unless specific cardiovascular conditions are present.

A. "Perform breast self-examinations during the middle of your cycle." B. "Perform breast self-examinations while lying on your side." C. "Use small, circular motions, working vertically up and down across the breast." D. "Use the palm of your hand to detect the presence of any large masses under the skin."

Correct Answer is C

Explanation

A. "Perform breast self-examinations during the middle of your cycle.": The best time for premenopausal clients to perform a breast self-exam is 5-7 days after the menstrual period ends, when hormonal fluctuations are minimal, and the breasts are less tender.
B. "Perform breast self-examinations while lying on your side.": The recommended position for self-examination is lying flat with the arm on the side being examined raised above the head, as this spreads the breast tissue more evenly.
C. "Use small, circular motions, working vertically up and down across the breast.": The vertical strip method, using small circular motions, is the recommended technique for thorough breast self-examination. It ensures that all breast tissue is palpated, including the axillary area.
D. "Use the palm of your hand to detect the presence of any large masses under the skin.": The pads of the fingers, not the palm, are used to palpate the breast for lumps or abnormalities.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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