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
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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Related Questions
Correct Answer is C
Explanation
A. Serum glucose of 118 mg/dL: This value is slightly above the normal range but not critically elevated; it does not typically require immediate notification to the surgeon.
B. Blood urea nitrogen (BUN) of 16 mg/dL: This BUN level is within the normal range and does not suggest an immediate concern for surgical risk.
C. Serum sodium of 130 mEq/L: A serum sodium level of 130 mEq/L indicates hyponatremia, which can lead to serious complications including neurological symptoms and should be addressed prior to surgery.
D. Serum potassium of 3.9 mEq/L: This level is within the normal range and does not require immediate action related to surgery.
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
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