A nurse is assessing a client who is 1 hr postoperative following roux-en Y gastric bypass surgery. Which of the following findings is the priority for the nurse to report to the provider?
Client report of back pain of 7 on a 0 to 10 scale
Excoriated folds of the client's panniculus
Hypoactive bowel sounds upon auscultation
urine output of 80 mL in the past hour
The Correct Answer is A
Choice A rationale:
Postoperative pain management is crucial for the client's comfort and recovery.
Choice B rationale:
Excoriated folds of the client's panniculus might be related to skin irritation and can be addressed without immediate provider notification.
Choice C rationale:
Hypoactive bowel sounds can be expected after surgery and might not require immediate reporting.
Choice D rationale:
Urine output of 80 mL in the past hour might be influenced by various factors and is not as high a priority as severe pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Genital herpes can be transmitted through viral shedding even when there are no visible lesions.
Choice B rationale:
Oil-based lubricants can weaken latex condoms, increasing the risk of condom breakage.
Choice C rationale:
Maintaining hydration is important during outbreaks to support the body's immune response.
Choice D rationale:
Acyclovir can help manage outbreaks, but it does not cure the infection.
Correct Answer is A
Explanation
Choice A rationale:
Assessing for the client's immediate safety is the first priority in crisis intervention.
Choice B rationale:
Identifying social support is important but not the primary action in this situation.
Choice C rationale:
Instructing the client about coping skills is important, but immediate safety takes precedence.
Choice D rationale:
Exploring the client's perception of the event is valuable, but assessing for suicidality is more urgent.
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