A nurse is assessing a client who is 24 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
150 mL of greenish yellow NG drainage
Client requests medication for nausea
Urinary output of 250 mL over past 12 hr
Hypoactive bowel sounds
The Correct Answer is C
A. 150 mL of greenish yellow NG drainage: This amount and color of drainage are expected after abdominal surgery, as bile-stained gastric contents can be present. It does not indicate a complication that requires provider notification.
B. Client requests medication for nausea: Nausea is a common postoperative symptom, often managed with antiemetics. While it should be addressed, it is not an urgent finding that requires immediate provider notification.
C. Urinary output of 250 mL over past 12 hr: Oliguria, defined as urine output less than 30 mL/hr (or less than 400 mL in 24 hr), suggests inadequate renal perfusion, possibly due to hypovolemia or acute kidney injury. This finding requires prompt provider notification.
D. Hypoactive bowel sounds: Reduced bowel activity is common after abdominal surgery due to anesthesia and opioid use. While monitoring is necessary, hypoactive sounds alone are not an urgent concern unless accompanied by other signs of ileus or obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Instruct the client to report bleeding: While important, assessing for bleeding is not the immediate priority. Minor blood-tinged sputum can be expected, but significant bleeding should be reported. Ensuring airway protection comes first.
B. Inform the client they might experience a low-grade fever: A mild fever may occur within the first 24 hours after bronchoscopy due to irritation, but addressing airway safety and aspiration risk takes precedence.
C. Check the client's gag reflex: The gag reflex must return before offering oral intake to prevent aspiration. The local anesthetic used for the procedure can suppress the reflex, increasing the risk of aspiration if the client drinks or eats too soon.
D. Provide the client with sips of water: Fluids should not be given until the gag reflex has returned. Providing water too soon could result in aspiration, leading to complications such as pneumonia.
Correct Answer is D
Explanation
A. "I have trouble urinating if I eat acidic foods.": Difficulty urinating after consuming acidic foods is not associated with latex allergy. This symptom may be related to bladder irritation or interstitial cystitis rather than an immune response to latex-related proteins.
B. "I often have diarrhea after eating scrambled eggs.": Diarrhea after consuming eggs suggests a food intolerance or an allergy to egg proteins. However, egg allergy is not linked to an increased risk of latex allergy.
C. "I sometimes start to wheeze when I eat peanuts.": Wheezing after peanut consumption suggests a peanut allergy, which is not directly associated with latex allergy. However, individuals with multiple allergies may be at higher risk for allergic reactions in general.
D. "I break out in a rash when I eat strawberries.": A history of allergic reactions to strawberries suggests a possible latex-fruit syndrome. Certain fruits, such as strawberries, bananas, avocados, and kiwis, contain proteins similar to those found in latex, increasing the risk of latex hypersensitivity.
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