A nurse is caring for a client who is 1 day postoperative following abdominal surgery. Which of the following client statements indicates a need for further instruction?

"I will get up and walk with the physical therapy aide."

"I will do leg exercises every hour while I am awake."

"I will take off my antiembolic stockings before I go to bed."

"I will use a footstool while I sit in a chair."

Answer and Explanation

The Correct Answer is C

A.   Getting up and walking with the physical therapy aide promotes early mobility and is a positive statement.
B.   Doing leg exercises every hour while awake helps prevent complications such as deep vein thrombosis (DVT).
C.   Leaving antiembolic stockings on during sleep helps prevent DVT, so the client's statement is incorrect.
D.   Using a footstool while sitting in a chair promotes proper positioning and comfort.

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Correct Answer is C

Explanation

A) Purulent drainage is indicative of pus, which is associated with infection and is typically thick and yellow, green, or brown.
B) Serous drainage is clear, thin, and watery, and is generally considered normal in the early stages of healing.
C) Sanguineous drainage, which is the correct answer, refers to drainage that contains or is mixed with blood, making it appear blood-tinged, and is expected in a fresh incision or one that is healing by secondary intention.
D) Hyperemia is not a type of drainage but a term that describes increased blood flow to an area of the body, resulting in redness. Therefore, the nurse should document the finding as sanguineous, which accurately describes blood-tinged drainage.

A. Decreased hematocrit B. Decreased specific gravity of urine C. Increased skin turgor D. Increased pulse rate

Correct Answer is D

Explanation

A. Decreased hematocrit may be seen in fluid volume excess, not deficit.

B. Decreased specific gravity of urine is more indicative of dilution rather than fluid volume deficit.
C. Increased skin turgor is a clinical manifestation of fluid volume deficit.

D. Increased pulse rate is a compensatory response to fluid volume deficit, reflecting the body's attempt to maintain perfusion in the setting of reduced blood volume.

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A nurse is caring for a client who is 1 day postoperative following abdominal surgery. Which of the following client statements indicates a need for further instruction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's incision and observes the drainage to be blood-tinged. The nurse should document this finding as which of the following?

Correct Answer is C

Explanation

A nurse is assessing a client who reports nausea and vomiting for 2 days. Which of the following indicates fluid volume deficit?

Correct Answer is D

Explanation

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