A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

Yellow-green drainage on the surgical incision

Blood pressure 102/66 mm Hg

Straw colored urine from an indwelling urinary catheter

Respiratory rate 18/min

Answer and Explanation

The Correct Answer is A

Yellow-green drainage from a surgical incision may indicate the presence of infection, especially if the drainage is purulent. This finding should be reported to the provider promptly for further evaluation and management to prevent complications such as wound infection or dehiscence.

A. Yellow-green drainage on the surgical incision: Yellow-green drainage suggests the presence of infection, which is a concerning finding in a postoperative client. It may indicate purulent drainage, which requires further assessment and possibly treatment with antibiotics.
B. Blood pressure 102/66 mm Hg: A blood pressure of 102/66 mm Hg is within the normal range for an adult client and does not typically require immediate intervention. However, trends in blood pressure should be monitored, especially if the client is symptomatic or if there are significant changes from the client's baseline.
C. Straw-colored urine from an indwelling urinary catheter: Straw-colored urine is a normal finding and indicates adequate hydration and kidney function. As long as the urine output is adequate and there are no other signs of urinary tract issues, this finding does not typically require immediate reporting.
D. Respiratory rate 18/min: A respiratory rate of 18 breaths per minute is within the normal range for an adult client and does not typically require immediate intervention. However, it's important to assess the client's respiratory status comprehensively, including oxygen saturation and lung sounds, to ensure adequate ventilation.

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Correct Answer is B, C, A, D

Explanation

Answer: B, C, A, D Rationale: B (Rescue the clients): The immediate priority in any fire situation is to ensure the safety of individuals, which includes removing clients from danger. C (Pull the fire alarm): After clients are safe, the next step is to alert others of the fire and call for assistance. A (Confine the fire): Once the alarm is activated, the fire should be contained by closing doors or windows to prevent it from spreading. D (Extinguish the fire): If it is safe to do so, the fire should be extinguished using the appropriate equipment. If not, evacuation is the next step.

A. Blood B. Parasites C. Steatorrhea D. Bacteria

Correct Answer is A

Explanation

A. Blood: The purpose of a stool guaiac test is to detect the presence of occult (hidden) blood in the stool. This test is commonly used to screen for gastrointestinal bleeding, which may indicate various conditions such as peptic ulcers, colorectal cancer, inflammatory bowel disease, or hemorrhoids. The guaiac test relies on the chemical reaction between guaiac resin and the heme component of hemoglobin in blood, resulting in a color change when blood is present in the stool.
B. Parasites: Stool tests for parasites typically involve examining stool samples under a microscope to identify the presence of parasitic organisms, such as protozoa or helminths. These tests are used to diagnose parasitic infections, such as giardiasis, cryptosporidiosis, or intestinal worms, rather than detecting blood in the stool.
C. Steatorrhea: Stool tests for steatorrhea assess the presence of excess fat in the stool, which may indicate malabsorption disorders, pancreatic insufficiency, or other gastrointestinal conditions affecting fat digestion and absorption. These tests involve analyzing stool samples for the presence of undigested fat globules rather than detecting blood.
D. Bacteria: Stool cultures are used to detect the presence of pathogenic bacteria in the stool, which may indicate bacterial infections such as Salmonella, Shigella, or Campylobacter. These tests involve culturing stool samples on specific media to identify bacterial pathogens rather than detecting blood. Stool guaiac tests specifically target the detection of occult blood and are not designed to identify bacteria in the stool.

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A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B, C, A, D

Explanation

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances?

Correct Answer is A

Explanation

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