When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

Low intermittent suction prescribed for the nasogastric tube is turned off.

A Hemovac drain is partially full of serous drainage and is not compressed.

The urinary catheter drainage bag is almost completely full of amber urine.

Oxygen is being administered via nasal cannula at 4 L/minute without humidification.

Answer and Explanation

The Correct Answer is D

A. This requires prompt attention but is not immediately life-threatening.

B.   This requires attention but does not pose an immediate threat to the client's condition.

C.   An almost completely full urinary catheter drainage bag requires attention but does not pose an immediate threat to the client's condition.
D.   Administering oxygen without humidification could lead to mucosal dryness and damage, and should be addressed promptly.

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Correct Answer is B

Explanation

A. Reconciling medication dosages is important but comes after verifying the accuracy of the prescriptions.
B. Comparing admission prescriptions with the client's previous medication list ensures continuity of care and prevents omissions or duplications.
C. Determining generic versus brand name medications can be addressed later after ensuring medication accuracy.
D. Client teaching is important but should follow the verification of the client's current medications.

A. Report when hematuria becomes pink tinged. B. Restrict all physical activities. C. Use the incentive spirometer. D. Monitor urinary stream for decreased output.

Correct Answer is D

Explanation

A. Pink-tinged hematuria is expected after the procedure, but reporting should be directed at increased bleeding or other signs of complications.
B. While some activity restrictions are necessary, a complete restriction of all physical activities is generally not advised and can lead to other complications like blood clots or decreased mobility.
C. An incentive spirometer is typically used to prevent respiratory complications post-surgery, but it is not specifically related to nephrolithotomy procedures.
D. Monitoring the urinary output is crucial because decreased output can indicate a blockage or other complications related to the nephrostomy tube.

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When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older client is being admitted to a rehabilitation unit from a medical-surgical unit following a left hip replacement. When reviewing the client's prescribed medications, which intervention should the nurse implement first?

Correct Answer is B

Explanation

The nurse is preparing a client for discharge who underwent a percutaneous nephrolithotomy with nephrostomy tube placement. Which instruction should the nurse include in the client's postoperative discharge teaching?

Correct Answer is D

Explanation

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