The nurse is assessing a client in the immediate post-operative setting. Which of the following finding requires priority intervention to prevent long-term complications?

Patient's refusal to cough, deep breathe, and use their incentive spirometer due to pain

Urine output of 40 mL/hr and clear yellow after having their Foley catheter removed

Patient ambulating short distances and performing range of motion exercises alter pain is controlled

Hypoactive bowel sounds 2 hours post-operative.

Answer and Explanation

The Correct Answer is A

A) Patient's refusal to cough, deep breathe, and use their incentive spirometer due to pain:
The patient’s refusal to perform these respiratory exercises could lead to serious complications such as atelectasis, pneumonia, and other respiratory issues. Coughing, deep breathing, and using the incentive spirometer are essential to prevent postoperative respiratory complications, especially if the patient is at higher risk for lung issues due to immobility or anesthesia. This needs immediate intervention to ensure the patient understands the importance of these activities and to address the pain issue, potentially with additional pain management or support.

B) Urine output of 40 mL/hr and clear yellow after having their Foley catheter removed:
A urine output of 40 mL/hr is within normal limits for a post-operative patient, and the clear yellow color indicates that the urine is not concentrated or indicative of infection. While monitoring urine output is important postoperatively, this finding suggests adequate renal function and does not indicate an immediate risk for long-term complications.

C) Patient ambulating short distances and performing range of motion exercises after pain is controlled:
Early ambulation and range of motion exercises are encouraged after surgery to promote circulation, prevent blood clots, and support overall recovery. It indicates that the patient is progressing in their recovery and actively participating in post-operative rehabilitation, which is a positive sign and does not need urgent intervention.

D) Hypoactive bowel sounds 2 hours post-operatively:
This is expected immediately after surgery, especially if the patient underwent abdominal surgery or received general anesthesia, which can temporarily reduce bowel motility. Hypoactive bowel sounds within the first few hours post-surgery are a normal response to anesthesia and do not require urgent intervention. The nurse should continue to monitor the patient’s bowel function, but this finding is not a priority in the immediate postoperative period.

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Correct Answer is D

Explanation

A. "You probably have a gastrointestinal infection":
This statement is incorrect. A positive result on the enzyme-linked immunosorbent assay (ELISA) indicates the presence of antibodies to HIV, which suggests exposure to the virus. It does not point to a gastrointestinal infection. HIV is a viral infection that primarily affects the immune system, not the gastrointestinal system. Misleading the client in this way would delay proper care and understanding of their health status.

B. "You are confirmed to be infected with the HIV virus.":
A positive ELISA test result does not automatically confirm an HIV diagnosis. ELISA is a screening test that detects HIV antibodies, but it can sometimes produce false-positive results. A positive ELISA result must be confirmed with a more specific confirmatory test, such as the Western blot test. Therefore, it would be premature to tell the client that they are "confirmed" to be infected with HIV without further confirmatory testing.

C. "This is a good result, which means you do not have HIV.":
This statement is also incorrect. A positive ELISA test result does not mean that the client does not have HIV. In fact, it indicates potential exposure to the virus. However, because the result is a screening test, it must be followed up with confirmatory testing. Telling the client that this is a "good result" would be misleading and could cause confusion or delay in appropriate care.

D. "Your result will need to be confirmed with a Western blot test.":
This is the correct response. The Western blot test is the confirmatory test used to verify a positive result from the ELISA. If the ELISA result is positive, the client should be informed that further testing, such as the Western blot, is needed to confirm the diagnosis of HIV infection. It is important to explain that the ELISA is a screening tool, and a positive result does not mean a definitive diagnosis without confirmation. This helps to set realistic expectations and ensures the client receives the appropriate follow-up care.

A. *Promptly change out of Wet clothing such as fitting suits after use B. "Buy synthetic underwear rather than cotton fabric C. "Be sure to empty your bladder every 6-8 hrs D. "Try to drink 500-1000 ml of fluid per day

Correct Answer is A

Explanation

A. "Promptly change out of wet clothing such as bathing suits after use":
This is a key recommendation for preventing urinary tract infections (UTIs), especially in women. Wet clothing, such as swimsuits or damp exercise clothes, creates a warm, moist environment that encourages bacterial growth, particularly in the genital and perineal areas. Changing out of wet clothing promptly helps reduce the risk of bacteria entering the urinary tract, which is an important preventive measure for recurrent UTIs.

B. "Buy synthetic underwear rather than cotton fabric":
This statement is incorrect. Cotton underwear is recommended because it is breathable and helps keep the genital area dry, reducing the likelihood of bacterial growth. Synthetic fabrics, on the other hand, trap moisture and heat, creating an environment where bacteria can thrive, increasing the risk of UTIs. Therefore, wearing cotton underwear is advised rather than synthetic fabric.

C. "Be sure to empty your bladder every 6-8 hours":
This recommendation is somewhat inaccurate. To prevent UTIs, it is essential to empty the bladder more frequently than every 6-8 hours, especially if the person feels the urge to urinate. Holding urine for long periods can increase the risk of bacterial growth in the urinary tract. It is generally recommended to urinate at least every 3-4 hours during the day to prevent urine stagnation and reduce the risk of infection.

D. "Try to drink 500-1000 ml of fluid per day":
This fluid intake recommendation is too low. To prevent UTIs, a higher fluid intake is necessary—typically 2-3 liters (2000-3000 mL) of fluid per day. Adequate hydration helps ensure frequent urination, which flushes out bacteria from the urinary tract. Consuming only 500-1000 mL of fluid per day is insufficient and would likely increase the risk of UTIs due to less frequent urination and less flushing of the urinary system.

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The nurse is assessing a client in the immediate post-operative setting. Which of the following finding requires priority intervention to prevent long-term complications?

Nursing Test Bank

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