A nurse is assisting with the care of client who is 6 hr postoperative. Which of the following findings should the nurse report to the provider?

Serosanguinous drainage on dressing

Hypoactive bowel sounds

Urinary output of 25 mL/hr

Pain level of 2 on 0 to 10 scale

Answer and Explanation

The Correct Answer is C

A. Serosanguinous drainage on dressing: Serosanguinous drainage, which is a mixture of clear and blood-tinged fluid, is a common and expected finding in the early postoperative period. It typically indicates normal healing unless the amount becomes excessive or the drainage changes character.

B. Hypoactive bowel sounds: Hypoactive bowel sounds are common within the first 24 to 48 hours following surgery, especially after general anesthesia or abdominal procedures. This finding is expected and does not immediately require provider notification unless accompanied by other concerning signs like severe abdominal distention.

C. Urinary output of 25 mL/hr: Urinary output should be at least 30 mL/hr to indicate adequate kidney perfusion and hydration. An output of 25 mL/hr suggests possible hypovolemia, renal impairment, or urinary retention, and it should be promptly reported to the provider for further evaluation.

D. Pain level of 2 on 0 to 10 scale: A pain score of 2 indicates mild pain, which is manageable and expected after surgery. This level of discomfort does not require urgent reporting to the provider as long as it remains controlled and does not interfere with recovery activities.

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Correct Answer is ["B","D","G","H","I"]

Explanation

Decreased respiratory effort, bilateral crackles: Reduced respiratory effort following opioid administration suggests opioid-induced respiratory depression. Crackles may indicate early airway compromise due to poor ventilation or fluid accumulation, requiring immediate intervention to support breathing.
Somnolent: Somnolence beyond expected postoperative drowsiness, especially in combination with other signs of opioid overdose, indicates central nervous system depression. The client is difficult to arouse, raising concern for airway and breathing compromise.
Pinpoint pupils: Pinpoint pupils are a hallmark sign of opioid toxicity. In the setting of recent morphine administration and accompanying respiratory depression, this finding confirms that opioid overdose is likely occurring and must be treated promptly.
Respiratory rate 10/min: A respiratory rate under 12 breaths per minute following opioid administration is a major red flag for opioid-induced respiratory depression. Immediate action is needed to prevent further decline in respiratory status, including potential use of naloxone.
Blood pressure 98/58 mm Hg: The client’s blood pressure has dropped significantly compared to the earlier reading, suggesting opioid-related hypotension. While not yet critically low, the trend combined with other overdose signs indicates instability needing close monitoring and intervention.
Heart rate 58/min: Although the client is bradycardic, this alone is not the most urgent issue compared to respiratory depression and neurological decline. It should still be monitored closely, but it is less immediately life-threatening than the airway and breathing concerns.
Temperature 37.4° C (99.4° F): This temperature is within normal range and does not require follow-up. There are no indications of infection or thermoregulatory issues based on the current temperature.

A. “I will empty the pouch every 2 to 3 hours." B. “I will no longer be able to eat nuts." C. “I should expect my stool to be unformed." D. "I will notify my doctor if the stoma starts to look purple."

Correct Answer is D

Explanation

A. "I will empty the pouch every 2 to 3 hours.": While it is important to empty the pouch when it is about one-third to half full, emptying it every 2 to 3 hours is unnecessary unless output is extremely high. Frequent emptying is based on the volume of stool, not strict timing.

B. "I will no longer be able to eat nuts.": Clients with a sigmoid colostomy typically resume a normal diet after healing, including nuts, unless otherwise instructed. Nuts are more commonly restricted after ileostomies due to the risk of obstruction, not sigmoid colostomies.

C. "I should expect my stool to be unformed.": Stool from a sigmoid colostomy is usually formed or semi-formed because it comes from the end of the colon where water absorption has mostly occurred. Unformed stool is more characteristic of ileostomies.

D. "I will notify my doctor if the stoma starts to look purple.": A healthy stoma should appear pink to red and moist. A purple, dark, or dusky stoma indicates impaired blood flow or ischemia and requires immediate medical evaluation to prevent serious complications.

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Body System	Findings
Cardiovascular	S1, S2, no murmur, bradycardia
Respiratory	decreased respiratory effort, equal chest expansion, bilateral crackles
Neurologic	somnolent
Head, Ears, Eyes, Nose, and Throat (HEENT)	oropharynx clear, mucous membranes moist, pinpoint pupils
Vital Signs	Temperature 37.4° C (99.4° F) Heart rate 58/min Respiratory rate 10/min Blood pressure 98/58 mm Hg

A nurse is assisting with the care of client who is 6 hr postoperative. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","D","G","H","I"]

Explanation

A nurse is reinforcing teaching for a client who has a new sigmoid colostomy. Which of the following comments by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

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