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 A
Explanation
A. Palpate the dorsalis pedis pulse: Assessing distal pulses ensures adequate circulation to the affected extremity. Impaired blood flow can indicate compartment syndrome or vascular compromise, which are serious complications following fracture stabilization. The nurse should also monitor capillary refill, skin temperature, and sensation.
B. Maintain the affected extremity in a dependent position: Keeping the extremity in a dependent position can increase swelling and venous congestion, leading to complications such as compartment syndrome. Elevation is recommended to minimize edema and promote venous return.
C. Wrap sterile gauze on the sharp point of the pins: The pin sites should be left uncovered to allow for proper monitoring of signs of infection or loosening. Instead, pin site care should be performed per facility protocol to reduce infection risk.
D. Adjust the clamps on the fixator frame: Adjusting the external fixator clamps is outside the nurse's scope of practice. Any modifications to the device should be performed by the orthopedic provider to prevent improper alignment and complications.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"}}
Explanation
Diabetes:
• Weight
• Blood glucose
Pancreatitis:
• None
Hyperthyroidism:
• Heart rate
• T3 level
Rationale:
• Weight: The client has experienced unintended weight loss, which is a common symptom of diabetes due to the body's inability to use glucose effectively, leading to fat and muscle breakdown.
• Heart rate: Tachycardia is a hallmark of hyperthyroidism due to increased metabolic activity and sympathetic nervous system stimulation.
• T3 level: The T3 level is within the normal range but on the higher end, which can still support hyperthyroidism when considered with other clinical findings.
• Blood glucose: An elevated blood glucose level of 250 mg/dL is consistent with diabetes, as normal fasting levels are below 106 mg/dL.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.