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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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Intraosseous line: Intraosseous lines are used for emergency situations when peripheral access is not available, and are not suitable for long-term chemotherapy administration due to the risk of complications and discomfort.
B. Intrathecal catheter: Intrathecal catheters are used for delivering medication directly into the spinal canal. They are not suitable for systemic chemotherapy administration, which requires vascular access.
C. Peripheral intravenous line: Peripheral intravenous lines are typically used for short-term treatments. They are not ideal for long-term chemotherapy because they need frequent replacement, and the veins can become damaged from prolonged use of chemotherapeutic agents.
D. Subcutaneous implantable port: A subcutaneous implantable port is the best option for long-term chemotherapy. It is implanted under the skin, reducing the risk of infection, and provides a stable and reliable access point for repeated treatments over several months.

A. 10% dextrose in water B. 10% dextrose in 0.45% sodium chloride C. 0.9% sodium chloride D. 2.5% sodium chloride

Correct Answer is C

Explanation

A. 10% dextrose in water: This solution is used primarily for providing calories and is not suitable for volume replacement.
B. 10% dextrose in 0.45% sodium chloride: This solution combines dextrose and a hypotonic sodium chloride solution, which is not ideal for immediate volume replacement in severe bleeding cases.
C. 0.9% sodium chloride: This is the correct choice. Normal saline (0.9% sodium chloride) is an isotonic solution used for volume replacement, especially in cases of significant blood loss.
D. 2.5% sodium chloride: This is a hypotonic solution and would not be appropriate for volume replacement in severe bleeding as it does not adequately address the need for fluid resuscitation.

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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?

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Correct Answer is C

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