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
None
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Protamine sulfate reverses heparin, not midazolam, a benzodiazepine requiring flumazenil for reversal. Assuming protamine is needed risks ineffective response to oversedation, critical to avoid in ensuring rapid reversal and safety in clients post-moderate sedation with midazolam in surgical settings.
Choice B reason: Acetylcysteine treats acetaminophen overdose, not midazolam, reversed by flumazenil. Assuming acetylcysteine is appropriate risks delayed reversal of sedation, potentially causing respiratory depression, critical to prevent in ensuring safe recovery for clients post-moderate sedation with midazolam in postoperative care.
Choice C reason: Flumazenil reverses midazolam’s benzodiazepine effects, critical for managing oversedation or respiratory depression post-moderate sedation. Having it on hand ensures rapid response, essential for client safety, preventing complications, and supporting recovery in surgical settings using midazolam for procedural sedation.
Choice D reason: Naloxone reverses opioids, not midazolam, a benzodiazepine requiring flumazenil. Assuming naloxone is needed risks ineffective treatment of sedation, potentially prolonging respiratory risks, critical to avoid in ensuring proper reversal and safety in clients post-moderate sedation with midazolam.
Correct Answer is D
Explanation
Choice A reason: Pork is prohibited in Islam (haram), and including it during Ramadan violates dietary laws, disrespecting the client’s faith. Scheduling meals after sundown respects fasting. Offering pork risks cultural insensitivity, potentially causing distress, critical to avoid in ensuring respectful, patient-centered care during Ramadan.
Choice B reason: Avoiding red meat is not a Ramadan or Islamic requirement; Muslims may consume halal red meat after sundown. Scheduling meals post-sundown is key. Assuming red meat avoidance risks unnecessary dietary restriction, potentially affecting nutrition, critical to prevent in supporting client health during fasting periods.
Choice C reason: Waiting 1 hour after dairy to serve poultry is not an Islamic dietary rule; it may reflect kosher practices. Scheduling meals after sundown aligns with Ramadan fasting. This assumption risks cultural confusion, delaying meals, critical to avoid in ensuring timely nutrition for Muslim clients during Ramadan.
Choice D reason: Scheduling meals after sundown respects Ramadan fasting, when Muslims eat during non-daylight hours (iftar). This ensures nutritional needs are met, critical for health, maintaining cultural sensitivity, and supporting client comfort, aligning with patient-centered care principles for devout Muslims observing Ramadan in healthcare settings.
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