A nurse is assessing a client who is 6 hours postoperative following a total abdominal hysterectomy. Which of the following findings should the nurse report to the provider?

The client has decreased bowel sounds in all four quadrants.

The client’s total urinary output is 75 mL in the last 3 hours.

The client reports a pain level of 4 on a scale of 0 to 10.

The client’s dressing has a scant amount of dark red drainage.

None

Answer and Explanation

The Correct Answer is B

Choice A reason: Decreased bowel sounds 6 hours post-hysterectomy are expected due to anesthesia and surgical manipulation, typically resolving within 24-48 hours. Urinary output of 75 mL in 3 hours is more urgent. Assuming bowel sounds require reporting risks overlooking critical renal issues, potentially delaying intervention in postoperative care.

Choice B reason: Urinary output of 75 mL in 3 hours (25 mL/hour) is below the expected 30-50 mL/hour, indicating potential renal compromise or obstruction post-hysterectomy, requiring immediate reporting. This ensures timely intervention, critical for preventing acute kidney injury, ensuring fluid balance, and supporting recovery in postoperative clients.

Choice C reason: A pain level of 4 is moderate and manageable with routine analgesics, not requiring immediate provider reporting compared to low urinary output. Assuming pain is urgent risks misprioritizing, potentially delaying critical interventions for renal issues, essential for ensuring comprehensive postoperative care and client stability.

Choice D reason: Scant dark red drainage is expected 6 hours post-hysterectomy, indicating minor surgical oozing, not requiring immediate reporting. Low urinary output is priority. Assuming drainage is concerning risks diverting focus from renal complications, critical for preventing kidney injury and ensuring safe recovery in postoperative clients.

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Correct Answer is D

Explanation

Choice A reason: A semi-sitting position for meals is impractical in a hip spica cast, risking discomfort or aspiration; turning every 2 hours prevents pressure injuries. Assuming semi-sitting is correct risks complications, critical to avoid in ensuring safe positioning and care for children in spica casts.

Choice B reason: Maintaining dependent lower extremities increases edema risk in a hip spica cast; turning every 2 hours promotes circulation. Assuming dependent positioning is correct risks swelling, critical to prevent in ensuring proper cast care and comfort for children with hip spica casts.

Choice C reason: A bedside commode is unsuitable for a hip spica cast, which covers the pelvis; bedpans are used. Turning every 2 hours is key. Assuming a commode is appropriate risks impracticality, critical to avoid in ensuring proper toileting and care in spica cast management.

Choice D reason: Turning every 2 hours prevents pressure ulcers and promotes circulation in a child with a hip spica cast, critical for skin integrity and comfort. This ensures proper cast care, reducing complications, supporting healing, and maintaining safety in pediatric orthopedic management.

A. I will use a communication board to assess the client’s needs. B. I will use an interpreter when providing client teaching. C. I will use indirect lighting in the client’s room. D. I will collaborate with a speech therapist about the client’s plan of care.

Correct Answer is C

Explanation

Choice A reason: A communication board is for speech or cognitive issues, not visual impairment, where indirect lighting aids vision. Assuming a board is appropriate risks ineffective communication, potentially frustrating the client, critical to avoid in ensuring clear interaction for visually impaired clients in care settings.

Choice B reason: An interpreter is for language barriers, not visual impairment, where indirect lighting enhances visibility. Assuming an interpreter is needed risks misaligned communication strategies, potentially reducing clarity, critical to prevent in ensuring effective teaching and interaction for clients with visual impairments.

Choice C reason: Indirect lighting reduces glare, improving visibility for visually impaired clients, enhancing communication and safety. This understanding is critical for effective interaction, ensuring client comfort, promoting independence, and supporting accurate information exchange, essential for care delivery in clients with visual impairments.

Choice D reason: Collaborating with a speech therapist addresses speech issues, not visual impairment, where indirect lighting is key. Assuming therapist involvement is relevant risks overlooking visual needs, potentially reducing communication efficacy, critical to avoid in supporting visually impaired clients in healthcare settings.

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A nurse is assessing a client who is 6 hours postoperative following a total abdominal hysterectomy. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has a hip spica cast. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is discussing effective communication techniques with a newly licensed nurse for a client who has a visual impairment. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is C

Explanation

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