The nurse is changing a client’s abdominal surgical dressing. Which finding warrants notification to the healthcare provider?

Yellow purulent drainage.

Pink granulation tissue.

Serosanguineous fluid.

Approximated wound edges.

Answer and Explanation

The Correct Answer is A

Choice A reason: Yellow purulent drainage indicates wound infection, likely from bacterial proliferation (e.g., Staphylococcus aureus) causing pus. This serious complication risks delayed healing, abscess, or sepsis, necessitating provider notification for cultures, antibiotics, or surgical intervention. Infection disrupts tissue repair, requiring urgent management to prevent systemic spread or wound dehiscence.

Choice B reason: Pink granulation tissue is normal in wound healing, reflecting angiogenesis and fibroblast activity during the proliferative phase. It indicates healthy tissue formation, not requiring notification. Purulent drainage, however, signals infection, a critical issue disrupting healing and risking complications, making it the priority finding for reporting.

Choice C reason: Serosanguineous fluid, a mix of serum and blood, is expected in early surgical wounds as capillaries heal. It does not indicate infection unless excessive. Purulent drainage is more urgent, directly suggesting bacterial infection, which can lead to serious complications like sepsis, requiring immediate provider attention.

Choice D reason: Approximated wound edges indicate proper closure and healing, reducing scarring and infection risk. This positive finding does not warrant notification. Yellow purulent drainage, conversely, signals infection, a critical complication requiring urgent intervention to prevent further tissue damage or systemic infection, making it the priority.

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Correct Answer is B

Explanation

Choice A reason: Discouraging straining on stool prevents pain exacerbation or constipation in cancer but is not the priority with a pain score of 9. Severe pain from bone metastases, stimulating nociceptors, requires urgent IV narcotics to improve comfort, addressing the primary palliative goal over secondary issues like straining.

Choice B reason: A pain score of 9 in metastatic bone cancer indicates severe nociceptive pain from tumor invasion. IV narcotics (e.g., morphine) rapidly bind opioid receptors, reducing pain perception. This prioritizes comfort in palliative care, especially with stable vitals (SpO₂ 95%), addressing pain before nausea in this critical scenario.

Choice C reason: An IV fluid bolus treats dehydration from vomiting but does not address severe pain (9/10), a palliative priority. Bone metastases cause intense pain, requiring narcotics. Fluids are secondary, as vitals (BP 110/80) suggest stability, making pain relief more urgent to enhance quality of life in palliative care.

Choice D reason: An IV antiemetic controls nausea, likely from tumor or treatment effects, but severe pain (9/10) is the priority in palliative care. Narcotics provide rapid relief for bone metastasis pain, improving comfort. Antiemetics are secondary, as pain significantly impacts quality of life more immediately than nausea.

A. Evaluate amount of urinary output hourly. B. Clamp the catheter for 5 minutes hourly. C. Secure the ureteral catheter to the client’s leg. D. Report urine leakage around ureteral catheter.

Correct Answer is D

Explanation

Choice A reason: Evaluating urinary output hourly monitors renal function post-ureterolithotomy, as obstruction or complications may reduce output. However, urine leakage around the catheter suggests dislodgement or ureteral injury, risking peritonitis or infection. Reporting leakage is more urgent, as it indicates a critical catheter malfunction requiring immediate medical attention.

Choice B reason: Clamping the ureteral catheter risks obstructing urine flow, increasing pressure and causing ureteral damage or reflux, potentially leading to hydronephrosis or infection. Leakage around the catheter is a more pressing issue, indicating possible perforation or displacement, necessitating urgent reporting to prevent severe complications.

Choice C reason: Securing the catheter prevents dislodgement but is routine. Urine leakage suggests a critical issue like catheter malfunction or ureteral injury, which could cause peritonitis or fistula. Reporting leakage takes precedence, as it addresses a potentially life-threatening complication, ensuring timely intervention over standard catheter care.

Choice D reason: Reporting urine leakage is critical, as it may indicate catheter displacement or ureteral perforation, risking peritonitis or infection. Leakage suggests the catheter fails to drain urine properly, a serious post-surgical issue requiring immediate assessment, potentially via imaging or surgical correction, to prevent renal or systemic complications.

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The nurse is changing a client’s abdominal surgical dressing. Which finding warrants notification to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Following a ureterolithotomy, the client has a ureteral catheter in place. Which intervention should the nurse implement?

Correct Answer is D

Explanation

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