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 {"dropdown-group-1":"A","dropdown-group-2":"E"}
Explanation
Correct choices are; Metabolic acidosis:
This can occur due to the client's diarrhea, leading to loss of bicarbonate (HCO3-) through the gastrointestinal tract. The ABG results show a pH slightly below normal (7.33) and a decreased bicarbonate level (19 mEq/L), indicative of metabolic acidosis.
Hypernatremia:
The client's sodium level is elevated at 149 mEq/L (normal range is 136-145 mEq/L). This indicates hypernatremia, which could be due to dehydration from diarrhea and possibly inadequate fluid intake.
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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