A nurse is assessing a patient who is 48 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
Blood pressure 102/66 mm Hg
Yellow-green drainage on the surgical incision
Respiratory rate 18/min
Straw-colored urine from an indwelling urinary catheter
The Correct Answer is B
Choice A rationale
A blood pressure of 102/66 mm Hg is within the normal range and would not typically need to be reported to the provider.
Choice B rationale
Yellow-green drainage on the surgical incision could be a sign of a wound infection. Infections after surgery can lead to serious complications and should be reported to the provider immediately.
Choice C rationale
A respiratory rate of 18/min is within the normal range and would not typically need to be reported to the provider.
Choice D rationale
Straw-colored urine from an indwelling urinary catheter is normal and would not typically need to be reported to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The maximum duration for the total infusion time of packed red blood cells should be 4 hours. This is to ensure the safety and efficacy of the transfusion. Transfusing the blood too quickly can lead to complications, while taking too long can result in the blood becoming unusable.
Correct Answer is A
Explanation
Choice A rationale
Anemia due to excessive blood loss during surgery can lead to a variety of symptoms. One of the most common symptoms is fatigue. This is because anemia results in a decrease in the amount of oxygen that can be delivered to the body’s tissues, leading to a lack of energy and feelings of exhaustion. Therefore, a nurse should expect to find fatigue in a postoperative client who has anemia due to excessive blood loss during surgery.
Choice B rationale
Bradycardia, or a slower than normal heart rate, is not typically associated with anemia. Instead, anemia can actually lead to tachycardia, or a faster than normal heart rate, as the body tries to compensate for the decreased oxygen carrying capacity of the blood.
Choice C rationale
Hypertension, or high blood pressure, is not a typical finding in patients with anemia. In fact, in severe cases, anemia can lead to hypotension, or low blood pressure, due to a decrease in the blood’s ability to carry oxygen.
Choice D rationale
Diarrhea is not a common symptom of anemia. Anemia due to excessive blood loss during surgery is more likely to result in symptoms related to a lack of oxygen in the body’s tissues, such as fatigue, weakness, and shortness of breath.
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