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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Decrease the TPN rate to 60 ml/hr: Gradually decreasing the TPN rate is a common practice, but it is typically done in conjunction with transitioning to another form of nutrition, not as a standalone order.
B. Replace TPN infusion with an intravenous dextrose solution: This is the correct choice. When weaning off TPN, it is important to prevent hypoglycemia by replacing the TPN with a dextrose solution to maintain blood glucose levels while transitioning to oral or enteral feeding.
C. Begin infusion of 0.9% normal saline at 30 ml/hr: While saline may be used for hydration, it does not address the need to manage blood glucose levels during the transition from TPN.
D. Discontinue TPN infusion: Discontinuing TPN abruptly can lead to complications such as hypoglycemia. It is important to gradually taper off TPN while replacing it with a dextrose solution.
Correct Answer is D
Explanation
A. The 22-year-old client who does not understand English: This client can still consent legally if provided with a translator or interpreter to ensure understanding.
B. The 17-year-old client who has two fractured wrists: This client is a minor and would typically need a legal guardian to consent, but their ability to consent is not the primary issue here.
C. The 65-year-old client who cannot read or write: Literacy issues do not necessarily preclude the ability to understand and consent, especially if the consent process is explained to them.
D. The 80-year-old client who is not oriented to the day: This client lacks orientation and thus may not be able to fully understand or make an informed decision about the surgery, affecting their ability to consent legally.
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