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 A
Explanation
Choice A rationale
Hip arthroplasty, or hip replacement surgery, is a procedure that has been associated with a higher risk of deep vein thrombosis (DVT)8910. This is due to factors such as the length of the
procedure, the immobility of the patient during and after the procedure, and the location of the surgery in the lower extremities.
Choice B rationale
Cataract extraction is not typically associated with a high risk of DVT8910. This is a relatively quick and minimally invasive procedure, and it does not involve the lower extremities, which are the most common sites for DVT8910.
Choice C rationale
Myringotomy, a procedure to drain fluid from the middle ear, is not associated with a high risk of DVT8910. This is a quick and minimally invasive procedure, and it does not involve the lower extremities.
Choice D rationale
Laparoscopic appendectomy, while a surgical procedure, is not typically associated with a high risk of DVT8910. The risk of DVT is generally lower with laparoscopic procedures compared to open surgeries.
Correct Answer is D
Explanation
Choice A rationale
An increase in intraocular pressure is not a cause of diabetic retinopathy. Diabetic retinopathy is caused by damage to the blood vessels in the retina due to high blood sugar levels.
Choice B rationale
While regular eye exams are important for patients with diabetes mellitus, having an eye exam every 2 years may not be sufficient for detecting and managing diabetic retinopathy. More frequent eye exams may be recommended depending on the patient’s condition.
Choice C rationale
Clouding of the lens is not a manifestation of diabetic retinopathy. This is a symptom of cataracts, not diabetic retinopathy. Diabetic retinopathy affects the blood vessels in the retina, not the lens of the eye.
Choice D rationale
Seeing spots, also known as floaters, is a common symptom of diabetic retinopathy. This occurs when blood and other fluids leak into the vitreous, the clear, jelly-like substance that fills the inside of the eye.
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