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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Swimming is contraindicated with a fiberglass cast, as water exposure risks skin irritation or cast damage. A hair dryer relieves itching. Allowing swimming risks infection or cast breakdown, critical to avoid in ensuring proper healing and parental education for children with arm casts.

Choice B reason: Positioning the arm in a sling at bedtime is unnecessary; elevation on pillows promotes circulation. A hair dryer addresses itching. Assuming a sling is required risks discomfort, critical to prevent in ensuring proper cast care and comfort for children post-fracture.

Choice C reason: Using a hair dryer on a cool setting safely relieves itching under a fiberglass cast, preventing skin irritation from scratching. This instruction is critical for comfort, ensuring proper cast care, supporting healing, and educating parents on safe management of a child’s arm cast post-injury.

Choice D reason: Checking finger movement every 6 hours is insufficient; frequent checks (e.g., every 2-4 hours) ensure circulation. A hair dryer is correct for itching. Assuming 6-hour checks risks delayed detection of complications, critical to avoid in ensuring safe cast care for children with fractures.

A. Persistent headache. B. Weight gain 2.3 kg (5 lb). C. Frequent nausea. D. Breast tenderness.

Correct Answer is A

Explanation

Choice A reason: Persistent headache on oral contraceptives may indicate serious complications like stroke or hypertension, requiring immediate reporting to prevent life-threatening events. This is critical for timely intervention, ensuring client safety, and guiding potential medication adjustments in women using hormonal contraception for 6 months.

Choice B reason: Weight gain of 2.3 kg is common with oral contraceptives and not urgent, unlike persistent headache, which signals serious risks. Assuming weight gain requires reporting risks overlooking critical neurological symptoms, critical to avoid in ensuring safe monitoring of contraceptive side effects.

Choice C reason: Frequent nausea is a common contraceptive side effect, typically managed with counseling, not urgent like headache. Assuming nausea is priority risks delaying serious symptom evaluation, critical to prevent in ensuring timely reporting of potentially life-threatening complications in contraceptive users.

Choice D reason: Breast tenderness is a common, non-urgent side effect of oral contraceptives, unlike persistent headache, which may indicate stroke risk. Assuming tenderness is urgent risks missing critical symptoms, critical to avoid in ensuring proper monitoring and safety in clients on hormonal contraception.

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A nurse is assessing a client following abdominal surgery. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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