A nurse is assessing a client following abdominal surgery. Which of the following findings should the nurse report to the provider?
Temperature 37.6°C (99.7°F).
Serous drainage on abdominal dressing.
Urinary output 20 mL/hr.
Blood pressure 100/70 mm Hg.
The Correct Answer is C
Choice A reason: A temperature of 37.6°C is normal post-surgery, not requiring reporting; low urinary output is urgent. Assuming temperature is concerning risks overlooking renal issues, potentially delaying intervention, critical to avoid in ensuring comprehensive postoperative monitoring and client safety after abdominal surgery.
Choice B reason: Serous drainage is expected post-abdominal surgery, indicating normal healing, not requiring reporting. Low urinary output is priority. Assuming drainage is urgent risks misprioritizing, potentially neglecting renal complications, critical to prevent in ensuring proper postoperative care and recovery in surgical clients.
Choice C reason: Urinary output of 20 mL/hr is below normal (30-50 mL/hr), indicating potential renal impairment or dehydration post-surgery, requiring immediate reporting. This ensures timely intervention, critical for preventing kidney injury, maintaining fluid balance, and supporting recovery in clients post-abdominal surgery.
Choice D reason: Blood pressure of 100/70 mm Hg is low but not critical unless symptomatic; low urinary output is more urgent. Assuming blood pressure requires reporting risks overlooking renal issues, critical to avoid in ensuring prioritized monitoring and intervention in postoperative abdominal surgery clients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Aspirin is contraindicated in peptic ulcer disease due to its antiplatelet and gastric irritant effects, risking bleeding or ulcer exacerbation. Acetaminophen is safer. Administering aspirin risks gastrointestinal hemorrhage, critical to avoid in ensuring safe pain management for clients with a history of peptic ulcers.
Choice B reason: Ibuprofen, an NSAID, irritates the gastric mucosa, worsening peptic ulcers and increasing bleeding risk, making it unsuitable. Acetaminophen is preferred. Administering ibuprofen risks ulcer perforation or bleeding, critical to prevent in ensuring safe headache relief for clients with a peptic ulcer history.
Choice C reason: Ketorolac, an NSAID, is contraindicated in peptic ulcer disease due to its potent gastric irritant effects, risking ulcer aggravation or bleeding. Acetaminophen is safe. Administering ketorolac risks severe gastrointestinal complications, critical to avoid in providing safe pain management for clients with peptic ulcer history.
Choice D reason: Acetaminophen is safe for headache relief in peptic ulcer clients, lacking gastric irritant effects, avoiding risks of bleeding or ulcer worsening. Administering it ensures effective pain management, critical for client comfort, preventing gastrointestinal complications, and supporting safe care in clients with a history of peptic ulcers.
Correct Answer is A
Explanation
Choice A reason: Unleavened bread (matzah) is required during Passover in Orthodox Judaism, as leavened products are prohibited. Providing it respects dietary laws, critical for cultural sensitivity, ensuring nutritional needs, and supporting client comfort, aligning with patient-centered care principles during religious observances in healthcare settings.
Choice B reason: Chicken with cream sauce is prohibited during Passover, as Orthodox Jews avoid mixing meat and dairy (kosher laws). Unleavened bread is appropriate. Serving this risks dietary violation, causing distress, critical to avoid in ensuring culturally sensitive care for clients observing Passover in healthcare settings.
Choice C reason: Fish with fins and scales is kosher and permitted during Passover, not to be avoided. Unleavened bread aligns with Passover rules. Assuming fish avoidance risks unnecessary restriction, potentially affecting nutrition, critical to prevent in supporting dietary adherence for Orthodox Jewish clients during Passover.
Choice D reason: Lamb is permitted during Passover if kosher, not universally avoided. Unleavened bread is a dietary staple. Assuming lamb avoidance risks misaligned care, potentially causing nutritional or cultural issues, critical to avoid in ensuring respectful, adherent care for Orthodox Jewish clients observing Passover.
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