Which of the following post-surgical clients warrant an immediate follow up by the nurse? (Select all that apply.)
Patient with lung surgery has 20 ml/hr of urine output via catheter.
Patient with appendix surgery has thready pulse and blood pressure is 90/60.
Patient with knee surgery has approximated incision.
Patient with femoral artery surgery has strong pedal pulse.
Patient with bladder surgery has bloody urine within the first 12 hours.
Correct Answer : A,B,E
A. A urine output of 20 ml/hr is considered inadequate and may indicate decreased kidney perfusion or function. This client likely needs immediate assessment and intervention to address potential renal complications.
B. A patient with appendix surgery exhibiting a thready pulse and a blood pressure of 90/60 should be followed up immediately, as these signs can indicate shock, which is a medical emergency.
C. An approximated incision indicates that the wound edges are well-aligned and healing is progressing as expected. This does not typically warrant immediate follow-up unless there are signs of infection or other complications.
D. A strong pedal pulse suggests adequate blood flow distal to the surgical site. This is a positive finding and does not typically require immediate follow-up unless there are signs of vascular compromise or other complications.
E. A patient with bladder surgery having bloody urine within the first 12 hours can be expected, but if the bleeding is heavy or increases, it would warrant immediate follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A hematocrit of 40% is within the normal range for females, which is typically around 37-47%. This result is not concerning and does not typically require immediate notification to the surgeon.
B. A creatinine level of 0.9 mg/dL is within the normal range for adults (normal range varies slightly among laboratories but is generally around 0.5-1.1 mg/dL). This result indicates normal kidney function and does not require immediate notification.
C. A white blood cell (WBC) count of 20,000/mm3 is elevated above the normal range, which is typically between 4,500-11,000/mm3. An elevated WBC count could indicate infection or inflammation. Given the client is preoperative, an elevated WBC count may suggest an underlying infection that needs to be addressed before proceeding with surgery. The nurse should notify the surgeon promptly so appropriate evaluation and management can be initiated.
D. A potassium level of 3.8 mEq/L is within the normal range (normal range is generally 3.5-5.0 mEq/L). This result is not concerning and does not require immediate notification to the surgeon.
Correct Answer is B
Explanation
A. Offering ice chips, might seem like a safe alternative, but it still poses a risk if the gag reflex is not intact.
B. Assessing the gag reflex is crucial before offering food or fluids to ensure the client can protect their airway and swallow safely. This response prioritizes safety and is appropriate to ensure the client does not aspirate.
C. Calling the healthcare provider to request orders for food and water may be necessary if there are specific protocols or if the client's condition requires further assessment or interventions before oral intake can be resumed. However, this response does not address the immediate need for comfort and hydration.
D. This response involves assessing the client's ability to swallow directly. While it addresses the client's request for water, it may not be the safest initial approach without first assessing the client's readiness and ability to swallow safely.
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