A nurse is monitoring a client who is 36 hr postoperative following a left knee arthroscopy. Which of the following findings should the nurse report to the provider?
Discoloration at the postoperative site
Urinary output 150 mL/hr
Client report of pain at the incision site
Blood pressure 78/38 mm Hg
The Correct Answer is D
A. Discoloration at the postoperative site: Mild bruising or ecchymosis around the incision is common after arthroscopy and generally expected. It does not usually indicate a complication requiring immediate reporting.
B. Urinary output 150 mL/hr: A urinary output of 150 mL/hr is above the minimum expected hourly output (typically 30 mL/hr) and suggests adequate renal perfusion. This finding does not require immediate notification.
C. Client report of pain at the incision site: Some pain at the incision site is expected postoperatively. While pain should be managed, reporting to the provider is not urgent unless it is uncontrolled or accompanied by other concerning signs.
D. Blood pressure 78/38 mm Hg: Hypotension at this level is significant and can indicate hypovolemia, bleeding, or shock. Immediate reporting to the provider is necessary to prevent organ hypoperfusion and initiate prompt interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Call EMS if a seizure lasts 5 min or more: Prolonged seizures lasting 5 minutes or longer can progress to status epilepticus, a medical emergency that requires immediate intervention to prevent hypoxia, brain injury, or other complications. Parents should be instructed to activate emergency services promptly if seizures exceed this duration or if multiple seizures occur without full recovery.
B. Restrain the child at the onset of the seizure: Physical restraint during a seizure can cause injury to both the child and caregiver. Safe seizure management includes protecting the child from nearby hazards while allowing the seizure to run its course, rather than attempting to forcibly stop movements.
C. Offer the child a bubble bath every evening: Bubble baths are not specifically related to seizure safety or management. While baths can be part of routine hygiene, parents should avoid leaving the child unattended in water due to the risk of drowning during a seizure episode.
D. Place the child in a prone position during the seizure: Placing a child in the prone position increases the risk of airway obstruction and aspiration. Standard seizure safety includes positioning the child on their side (lateral recumbent) to maintain airway patency and facilitate drainage of secretions.
Correct Answer is C
Explanation
A. "I will soak my feet in warm water every night.": Soaking feet can lead to skin maceration and increase the risk of infection, particularly in clients with diabetes who may have peripheral neuropathy or impaired circulation. Safe foot care recommends washing and gently drying feet without prolonged soaking.
B. "I will apply a moisturizing cream between my toes.": Applying moisturizer between the toes can create a moist environment that promotes fungal infections. Moisturizing should be limited to dry areas of the feet, avoiding skin folds and interdigital spaces.
C. "I will be sure to wear cotton socks.": Cotton socks help absorb moisture, reduce friction, and prevent excessive sweating, which lowers the risk of skin breakdown and infection. Proper sock choice is a key component of daily diabetic foot care and protects against ulcer formation.
D. "I will buy new shoes in the early morning hours.": Feet typically swell during the day, so shoes should be purchased later in the day when feet are at their largest. Buying shoes in the morning may result in footwear that is too tight and increases the risk of pressure sores or blisters.
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