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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?

A.

150 mL of greenish yellow NG drainage

B.

Client requests medication for nausea

C.

Urinary output of 250 mL over past 12 hr

D.

Hypoactive bowel sounds

Answer and Explanation

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.


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Related Questions

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

Anticipated:
• Administer an iron supplement.
• Refer for a nutritional consult.

Nonessential:
• Place the client on a low sodium diet.

Contraindicated:
• Restrict fluid intake.

Rationale:

• Administer an iron supplement: The client has iron deficiency anemia, indicated by low hemoglobin, hematocrit, RBC count, and ferritin levels. Iron supplementation is essential for replenishing iron stores and improving oxygen-carrying capacity.

• Refer for a nutritional consult: The client follows a vegan diet, which increases the risk of iron and vitamin B12 deficiencies. A nutritionist can provide dietary guidance to improve iron and vitamin intake through plant-based sources or supplementation.

• Place the client on a low sodium diet: Sodium restriction is typically necessary for conditions like hypertension, heart failure, or renal disease. There is no indication that

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"C"}}

Explanation

Anticipated:

  • Metoprolol 5 mg every 2 to 3 min up to three doses
  • Oxygen at 2 L/min via nasal cannula
  • Draw electrolytes along with Hgb and Hct
  • Morphine 6 mg IV bolus every 3 hr as needed for pain
  • Nitroglycerin 0.4 mg SL now may repeat every 5 min up to 3 doses

Nonessential:

  • Obtain daily weight

Contraindicated:

  • Atropine 0.5 mg IV bolus every 5 min up to 2 mg

Rationale:

  • Metoprolol 5 mg every 2 to 3 min up to three doses: Beta-blockers reduce myocardial oxygen demand by decreasing heart rate and blood pressure, making them beneficial in acute coronary syndrome. They should be used cautiously in patients with signs of heart failure or bradycardia.
  • Oxygen at 2 L/min via nasal cannula: Supplemental oxygen is recommended for clients with acute coronary syndrome when oxygen saturation is below 94% to optimize myocardial oxygen supply and prevent ischemia.
  • Draw electrolytes along with Hgb and Hct: Electrolytes are critical in evaluating myocardial function, and hemoglobin/hematocrit levels help assess perfusion and oxygen-carrying capacity.
  • Morphine 6 mg IV bolus every 3 hr as needed for pain: Morphine is used to relieve severe chest pain in myocardial infarction and reduce myocardial oxygen demand by decreasing anxiety and preload.
  • Nitroglycerin 0.4 mg SL now may repeat every 5 min up to 3 doses: Nitroglycerin dilates coronary arteries, improving oxygen delivery to the myocardium, and reduces preload and afterload, alleviating chest pain. It is a first-line treatment for angina and myocardial infarction but should be avoided in cases of hypotension.
  • Obtain daily weight: Daily weight monitoring is primarily used for fluid balance assessment in conditions like heart failure rather than for acute myocardial infarction management.
  • Atropine 0.5 mg IV bolus every 5 min up to 2 mg: Atropine is used to treat bradycardia. However, the client is tachycardic, so atropine would worsen the condition and is contraindicated.

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