A nurse is assessing a client 12 hours following an emergency abdominal surgery. Which assessment finding requires prompt collaboration with the primary health care provider?

Abdomen soft, surgical dressing has scant amount of old drainage

Client ambulating with minimal assistance, complaints of occasional nausea

Crackles bilaterally in bases of lungs, has incisional pain

Temperature 99.4°F (37.4°C), pulse 100 bpm, bowel sounds present

Answer and Explanation

The Correct Answer is C

A. Abdomen soft, surgical dressing has scant amount of old drainage: A soft abdomen and minimal old drainage from the surgical dressing are expected findings postoperatively. They do not indicate an immediate concern that requires prompt action.
B. Client ambulating with minimal assistance, complaints of occasional nausea: Ambulation and occasional nausea are common and generally expected postoperatively. These findings do not require urgent collaboration with the healthcare provider.
C. Crackles bilaterally in bases of lungs, has incisional pain: Crackles in the lungs can indicate fluid accumulation or atelectasis, which may lead to pneumonia or other respiratory complications. This finding, especially combined with recent surgery, requires prompt evaluation and intervention.
D. Temperature 99.4°F (37.4°C), pulse 100 bpm, bowel sounds present: A slightly elevated temperature and increased pulse are common after surgery. The presence of bowel sounds is a positive sign indicating the return of gastrointestinal function. These findings are not immediately concerning.

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Correct Answer is D

Explanation

A. Respiratory rate 24/min: A respiratory rate of 24/min indicates tachypnea, which can be a sign of ongoing fluid volume excess or other complications. This does not show effective treatment.
B. Blood pressure 138/86 mm Hg: While this blood pressure is within the higher range of normal, it does not specifically indicate effective treatment of fluid volume excess. Blood pressure alone is not a reliable indicator of fluid status.
C. Total urinary output 700 mL in 24 hours: A urinary output of 700 mL in 24 hours is below the normal range (typically 800-2000 mL per day) and suggests that the fluid volume excess has not been effectively treated. Adequate urinary output is a key indicator of effective fluid management.
D. Weight loss of 4 lb in 24 hours: A weight loss of 4 lb in 24 hours is a clear indicator that the client has lost excess fluid, which is the desired outcome in treating fluid volume excess. This demonstrates that the treatment has been effective in reducing fluid retention

A. Non-steroidal anti-inflammatory drugs B. Cyclooxygenase-2 inhibitors C. Opioid analgesics D. Non-opioid pain medications

Correct Answer is C

Explanation

A. Non-steroidal anti-inflammatory drugs: These typically cause gastrointestinal upset and potential bleeding but are less likely to cause respiratory depression, constipation, or hypotension.
B. Cyclooxygenase-2 inhibitors: These are a subset of NSAIDs with fewer gastrointestinal side effects but do not generally cause respiratory depression or hypotension.
C. Opioid analgesics: This is the correct choice. Opioid analgesics are known to cause respiratory depression, constipation, nausea, vomiting, and hypotension.
D. Non-opioid pain medications: These include medications like acetaminophen and NSAIDs, which are less likely to cause respiratory depression or hypotension.

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A nurse is assessing a client 12 hours following an emergency abdominal surgery. Which assessment finding requires prompt collaboration with the primary health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client being treated for fluid volume excess. Which assessment finding indicates that treatment has been effective?

Correct Answer is D

Explanation

A client is experiencing respiratory depression, constipation, nausea and vomiting, and hypotension after receiving pain medication. Which class of analgesics did this client most likely receive?

Correct Answer is C

Explanation

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