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: Alone time for reflection may increase rumination in alcohol use disorder, not fostering self-control; positive feedback reinforces coping. Assuming alone time helps risks isolation, potentially worsening stress, critical to avoid in supporting adaptive behaviors and recovery in clients with alcohol use disorders.
Choice B reason: Gradual alcohol reduction is not ideal for alcohol use disorder, where abstinence is often recommended; positive feedback supports coping. Assuming reduction is effective risks enabling continued use, delaying recovery, critical to prevent in fostering self-control and sobriety in clients with alcohol dependence.
Choice C reason: Having the partner monitor alcohol intake undermines client autonomy, not promoting self-control; positive feedback reinforces independence. Assuming partner responsibility risks dependency, potentially hindering personal accountability, critical to avoid in supporting self-managed recovery in clients with alcohol use disorder.
Choice D reason: Giving positive feedback for adaptive coping strategies reinforces healthy stress management, promoting self-control in alcohol use disorder. This builds confidence, critical for sustained sobriety, encouraging alternative coping mechanisms, and supporting long-term recovery, essential for effective behavioral change in clients managing stress without alcohol.
Correct Answer is B
Explanation
Choice A reason: Supervising return demonstration follows teaching, not initial assessment; determining knowledge is first. Assuming demonstration is the first step risks ineffective education, potentially leading to misuse, critical to avoid in ensuring proper diaphragm use and contraception efficacy for female clients.
Choice B reason: Determining the client’s knowledge about diaphragm use is the first step, guiding tailored education and ensuring effective use. This assessment is critical for addressing gaps, promoting adherence, preventing contraceptive failure, and supporting informed decision-making in female clients requesting diaphragms for contraception.
Choice C reason: Teaching insertion follows assessing knowledge, which identifies educational needs. Assuming teaching is first risks overlooking client understanding, potentially leading to incorrect use, critical to prevent in ensuring effective diaphragm contraception and client safety in reproductive health care.
Choice D reason: Documenting understanding is a later step after assessing and teaching; determining knowledge is priority. Assuming documentation is first risks premature recording, potentially missing educational needs, critical to avoid in ensuring comprehensive diaphragm education and effective contraception for female clients.
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