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
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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Related Questions
Correct Answer is C
Explanation
A. A room with another nonsurgical client: Placing a client with active tuberculosis in a room with another nonsurgical client is not appropriate because it increases the risk of transmission to other patients. Tuberculosis is highly contagious, and isolation precautions are necessary to prevent the spread of the disease.
B. A room in the ICU: While isolation precautions are necessary for a client with active tuberculosis, placing the client in the intensive care unit (ICU) may not be necessary unless the client requires critical care. However, the priority is to provide a room that meets the requirements for airborne infection isolation, which may not necessarily be in the ICU.
C. A room with air exhaust directly to the outdoor environment: This is the correct choice. A room with air exhaust directly to the outdoor environment is essential for a client with active tuberculosis. Airborne infection isolation rooms (AIIRs) have negative air pressure and special ventilation systems that prevent the circulation of air from the room to other areas of the healthcare facility, reducing the risk of transmission to healthcare workers and other patients.
D. A room that is within view of the nursing station: While it may be convenient for the nursing staff to have the client's room within view of the nursing station for monitoring purposes, the priority for a client with active tuberculosis is to ensure that they are placed in a room with appropriate airborne infection isolation precautions, including proper ventilation, to minimize the risk of transmission to others.
Correct Answer is D
Explanation
A. Relieve the client's pain: While pain management is important for client comfort and recovery, it is not the priority immediately following intermaxillary fixation. Pain relief can be addressed once the more urgent concerns, such as preventing aspiration, are addressed.
B. Promote oral hygiene: Promoting oral hygiene is essential for preventing complications such as infection, but it is not the priority immediately after surgery and intermaxillary fixation. The client's airway and respiratory status should be the primary focus at this time.
C. Ensure adequate nutrition: Ensuring adequate nutrition is important for the client's overall recovery, but it is not the immediate priority after surgery and intermaxillary fixation. The priority is to prevent complications such as aspiration and maintain the client's airway.
D. Prevent aspiration: This is the priority action for the nurse. Intermaxillary fixation restricts the client's ability to open their mouth, increasing the risk of aspiration if vomiting occurs. The nurse should ensure that the client's airway is clear and that measures are in place to prevent aspiration, such as positioning the client appropriately and monitoring for signs of respiratory distress.
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