A nurse is caring for a client who is postoperative following an open cholecystectomy. Which of the following assessment findings should the nurse report to the provider?
Report of shoulder pain
Thick, green-brown drainage on dressing
Incisional pain 5 out of 10 on a pain scale
Abdominal dressing dry and intact
The Correct Answer is B
This finding could indicate the presence of bile leakage, which can occur following a cholecystectomy. The provider should be notified immediately as the client may require further interventions. Incisional pain, shoulder pain, and a dry and intact abdominal dressing are expected findings in the postoperative period.
Choice A, reporting of shoulder pain, is not the correct answer because this is a common finding post-cholecystectomy, which is often due to the presence of carbon dioxide used during the surgical procedure.
Choice C, incisional pain 5 out of 10 on a pain scale, is not the correct answer because this level of pain is within the expected range for the postoperative period.
Choice D, abdominal dressing dry and intact, is not the correct answer because this is an expected finding in the postoperative period.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B, a client who had abdominal surgery 2 days ago and the incision line is separating. This client requires immediate attention as a separating incision can indicate wound dehiscence or evisceration, which are surgical emergencies. Choice A is incorrect because although C. difficile is a serious infection, liquid stools are a common symptom and do not require immediate attention. Choice C is incorrect because intermittent coughing up clear sputum is a normal finding for a client with a tracheostomy, and does not indicate a change in the client's condition. Choice D is incorrect because the client fell 12 hours ago and reports pain as 4 on a scale of 0 to 10, which indicates a low level of pain.
Choice A: A client who has Clostridium difficile and has liquid stools is incorrect because although C. difficile is a serious infection, liquid stools are a common symptom and do not require immediate attention.
Choice C: A client who has a chronic tracheostomy and is intermittently coughing up clear sputum is incorrect because intermittent coughing up clear sputum is a normal finding for a client with a tracheostomy, and does not indicate a change in the client's condition.
Choice D: A client who fell 12 hours ago and reports pain as 4 on a scale of 0 to 10 is incorrect because the level of pain is low and does not require immediate attention.
Correct Answer is ["A","D"]
Explanation
The correct answer is a. Dysuria and d. Hematuria.
Choice A rationale:
Dysuria, or painful urination, is a common symptom of cystitis due to the inflammation of the bladder lining.
Choice B rationale:
Bradycardia, or slow heart rate, is not typically associated with cystitis. Cystitis primarily affects the urinary system and does not usually impact heart rate.
Choice C rationale:
Pruritus, or itching, is not a common symptom of cystitis. Itching is more often associated with skin conditions or allergic reactions.
Choice D rationale:
Hematuria, or blood in the urine, can occur with cystitis due to the irritation and inflammation of the bladder lining.
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