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 A

Explanation

A. Ask the client's family about cultural or religious practices regarding postmortem care: Respecting the client's and family's cultural and religious preferences is an important aspect of providing dignified and individualized postmortem care. Some practices may have specific rituals that should be honored.

B. Remove the client's dentures from their mouth before rigor mortis begins: Dentures are usually placed back into the client's mouth, not removed, to maintain a natural facial appearance and support the facial structure before rigor mortis sets in.

C. Turn on all the lights in the room before the family views the client's body: Creating a calm, peaceful environment is preferred when the family views the body. Harsh lighting may feel overwhelming or intrusive during such an emotional time.

D. Position the client's bed flat without a pillow under their head: Elevating the head of the bed slightly and placing a pillow under the head can help prevent blood from pooling in the head and face, preserving a more natural appearance. Leaving the bed flat is not ideal.

A. Apply lotion between toes. B. Use a heating pad to warm feet. C. Apply cotton socks to feet daily D. Inspect appearance of feet weekly.

Correct Answer is C

Explanation

A. Apply lotion between toes: Lotion should not be applied between the toes because the moisture can promote fungal infections. Instead, lotion can be applied to the tops and bottoms of the feet to prevent dryness and cracking.

B. Use a heating pad to warm feet: Clients with diabetes often have decreased sensation in their feet and using heating pads can cause burns without them realizing it. Safer methods, like wearing warm socks, should be used to keep feet warm.

C. Apply cotton socks to feet daily: Wearing clean, dry cotton socks daily helps protect the feet, maintain warmth, and absorb moisture, reducing the risk of fungal infections and skin breakdown, which are common concerns for clients with diabetes.

D. Inspect appearance of feet weekly: Clients with diabetes should inspect their feet daily, not weekly. Daily inspection helps catch cuts, blisters, or signs of infection early to prevent serious complications such as ulcers or amputations.

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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?

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