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 C
Explanation
A. Suggest the family persuade the client to take the medication: While family support can encourage adherence, pressuring or coercing a client to take medication undermines the client’s autonomy and legal right to refuse treatment. Persuasion alone does not override informed refusal and is not an appropriate first action.
B. Recommend that the medication be delivered intramuscularly: Administering medication via injection without the client’s consent constitutes battery and violates ethical and legal standards. This intervention should only be considered under specific involuntary treatment protocols and court orders, not as a routine response to refusal.
C. Remind the newly licensed nurse that the client has a right to refuse medication: Clients with decision-making capacity have the right to accept or refuse treatment, including psychotropic medications. The charge nurse should reinforce this ethical and legal principle, ensuring that the newly licensed nurse understands the importance of respecting autonomy.
D. Suggest the newly licensed nurse contact the pharmacy to inquire about compatible foods: Attempting to hide medication in food without the client’s knowledge is considered covert administration and is ethically and legally inappropriate. Consultation about food compatibility does not address the fundamental issue of informed consent and client rights.
Correct Answer is ["C","D"]
Explanation
A. Basketball: Basketball is a high-impact, contact sport that involves frequent running, jumping, and potential collisions with other players. Children with hemophilia are at increased risk for joint and soft tissue bleeding from trauma, so participation in basketball is not recommended.
B. Gymnastics: Gymnastics involves tumbling, jumping, and apparatus use, which can lead to falls and injuries. These activities carry a high risk of trauma-induced bleeding for children with hemophilia, making it an unsafe choice.
C. Swimming: Swimming is a low-impact sport that promotes cardiovascular fitness, muscle strength, and joint mobility without significant risk of trauma. Water-based activities are safe for children with hemophilia, providing exercise benefits while minimizing bleeding risk.
D. Golf: Golf is a non-contact, low-impact sport that allows children to participate safely without high risk of injury. It promotes coordination, concentration, and mild physical activity without placing stress on joints or increasing the likelihood of bleeding.
E. Soccer: Soccer is a contact sport with frequent running, collisions, and potential falls, increasing the risk of bleeding in joints and muscles. For children with hemophilia, soccer is generally considered unsafe due to the high potential for injury.
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