A nurse is assessing a client who is 8 hr postoperative following a right-modified radical mastectomy. Which of the following should the nurse recognize as the priority finding?
Urinary output of 100 mL in 4 hr
Coughing frothy, pink secretions
Emesis of 110 mL of thick, yellow fluid
Red drainage on the dressing
The Correct Answer is B
A. Urinary output of 100 mL in 4 hr: This indicates a urine output of 25 mL/hr, which is slightly below the expected minimum of 30 mL/hr for adequate renal perfusion. While important to monitor, it is not immediately life-threatening compared to respiratory compromise.
B. Coughing frothy, pink secretions: Frothy, pink sputum can indicate pulmonary edema, a potentially life-threatening condition that requires immediate assessment and intervention to prevent respiratory failure. Airway and oxygenation take priority in the postoperative client.
C. Emesis of 110 mL of thick, yellow fluid: Postoperative vomiting is concerning for nausea or potential infection, but it is not immediately life-threatening. Management includes antiemetics and monitoring for dehydration.
D. Red drainage on the dressing: Some postoperative bleeding is expected, especially in the first few hours after surgery. While the nurse should monitor for excessive hemorrhage, small amounts of red drainage are less urgent than signs of pulmonary compromise.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Ground beef: Ground beef provides protein and iron but contains very little calcium, which is the primary nutrient of concern when dairy products are removed from the diet. Eliminating dairy increases the risk of inadequate calcium intake, and ground beef does not help replace this deficit. It does not address the nutritional gap caused by lactose intolerance.
B. Peanut butter: Peanut butter offers healthy fats and some protein but is not a meaningful source of calcium. While it can contribute to overall calorie and nutrient intake, it does not compensate for the loss of dairy-derived calcium. Relying on peanut butter alone would leave the client at risk for long-term bone health issues.
C. Kale: Kale is rich in calcium and is easily absorbed by the body, making it an ideal substitute when dairy intake is restricted. Including kale regularly helps maintain adequate calcium levels to support bone strength and neuromuscular function. It offers a plant-based solution that aligns well with the dietary needs of someone with lactose intolerance.
D. Canoes: Canoes are not a known food source and provide no nutritional relevance in replacing nutrients lost from eliminating dairy. They do not offer calcium or other minerals commonly supplied by milk or dairy products. This option does not support dietary adjustments needed to prevent nutrient deficiencies.
Correct Answer is D
Explanation
A. Decrease in blood pressure: Autonomic dysreflexia is characterized by a sudden increase in blood pressure, not a decrease. Hypotension is more typical of spinal shock, making low blood pressure inconsistent with autonomic dysreflexia.
B. Increase in heart rate: During autonomic dysreflexia, the body often responds with bradycardia rather than tachycardia due to baroreceptor-mediated parasympathetic activation. An elevated heart rate is not a typical sign of this condition.
C. Client report of eye twitching: Eye twitching is not associated with autonomic dysreflexia. This symptom may indicate a neurological or electrolyte issue, but it does not help identify the acute hypertensive crisis characteristic of autonomic dysreflexia.
D. Client report of sudden headache: A sudden, severe headache is a hallmark symptom of autonomic dysreflexia caused by abrupt hypertension. This finding, along with other signs such as flushed skin, nasal congestion, and sweating above the level of injury, indicates the need for immediate intervention to prevent complications such as stroke.
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