A nurse is caring for a client who is 2 hr postoperative. Which of the following findings should the nurse report to the provider?

The client reports a pain level of 2 on a 0 to 10 scale after administration of pain medication.

The client has a urine output of 50 mL/hr after removal of the indwelling urinary catheter.

The client has a wound dressing saturated with sanguinous drainage after it was reinforced.

The client has an oxygen saturation level of 96% after oxygen 2 L/min via nasal cannula was applied.

Answer and Explanation

The Correct Answer is C

Rationale:
A. The client reports a pain level of 2 on a 0 to 10 scale after administration of pain medication: A pain level of 2 indicates adequate pain control following surgery, showing that the prescribed analgesic regimen is effective. This finding does not require reporting.

B. The client has a urine output of 50 mL/hr after removal of the indwelling urinary catheter: A urine output of 50 mL/hr is within normal limits and indicates adequate renal perfusion. This finding suggests that kidney function and fluid balance are appropriate after surgery.

C. The client has a wound dressing saturated with sanguineous drainage after it was reinforced: Saturation of the surgical dressing with sanguineous drainage can indicate active bleeding or hemorrhage. Because this exceeds normal postoperative drainage and persists after reinforcement, it requires immediate notification of the provider.

D. The client has an oxygen saturation level of 96% after oxygen 2 L/min via nasal cannula was applied: An oxygen saturation of 96% indicates effective oxygenation and a positive response to therapy. This finding is within normal range and does not signal a complication.

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Correct Answer is C

Explanation

Rationale:
A. Mottled skin: Mottling is typically a late sign of poor perfusion or approaching death and does not indicate pain. It reflects circulatory changes rather than discomfort requiring analgesia.

B. Constricted pupils: Constricted pupils may result from certain medications or neurological changes, but they are not a reliable indicator of pain. Pupillary changes alone do not guide pain management.

C. Restlessness: Restlessness is a common manifestation of pain in clients receiving palliative care, especially when verbal communication is limited. Administering prescribed pain medication can help alleviate discomfort and improve comfort.

D. Cheyne-Stokes respirations: This irregular breathing pattern occurs in advanced illness or near end-of-life and is not an indicator of pain. It reflects neurological or metabolic changes rather than discomfort requiring analgesia.

A. A client who is receiving a blood transfusion and reports low-back pain B. A female client who is scheduled for chemotherapy and has an RBC count of 4.0 x105/uL (4.2 to 5.4 x106/uL) C. A client who is 24 hr postoperative following a transurethral resection of the prostate and has small blood clots in the drainage tubing D. A client who is 2 days postoperative following placement of an ascending colostomy and has shreds of bloody mucus in the bag

Correct Answer is A

Explanation

Rationale:
A. A client who is receiving a blood transfusion and reports low-back pain: Low-back pain during a blood transfusion indicates a possible acute hemolytic reaction caused by ABO incompatibility. This is a life-threatening emergency that requires immediate discontinuation of the transfusion and notifying the provider to prevent renal failure and shock.

B. A female client who is scheduled for chemotherapy and has an RBC count of 4.0 x10⁶/µL (4.2–5.4 x10⁶/µL): Although the RBC count is slightly low, this finding is not immediately life-threatening. The provider should be informed, but the client does not require urgent intervention.

C. A client who is 24 hr postoperative following a transurethral resection of the prostate and has small blood clots in the drainage tubing: Small clots are expected during the first 24 to 36 hours post-TURP due to residual bleeding from the surgical site.

D. A client who is 2 days postoperative following placement of an ascending colostomy and has shreds of bloody mucus in the bag: Small amounts of bloody mucus are normal during the early postoperative phase as the bowel mucosa heals.

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